1
|
Blitz SE, Hoffman SE, Stippler M, Huntoon K. Differential Time-To-Promotion Trajectories Among Female and Male Neurosurgeons Contribute to Gender Disparities in Academic Rank Achievement. World Neurosurg 2024; 183:157-163. [PMID: 38135149 DOI: 10.1016/j.wneu.2023.12.081] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/13/2023] [Accepted: 12/14/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Despite the increasing representation of females in neurosurgical training, the fraction of female to male neurosurgeons decreases dramatically as faculty rank (Assistant, Associate, or Full Professor) increases. To assess this discrepancy, we quantified self-reported time-to-promotion trajectories for female and male neurosurgeons holding academic appointments. METHODS In this cross-sectional institutional review board (IRB)-approved study, 147 female and 84 male neurosurgeons currently holding faculty positions in the US were contacted via email and invited to complete an anonymous, standardized survey. Respondents provided the calendar year of postgraduate training completion, promotion to different faculty ranks, geographic region of current practice (Western, Midwest, Southern, Northeast), and practice subspecialty. RESULTS The response rate was 44.2% for females and 59.5% for males, with 114 participants included (65 female, 49 male). On average, female neurosurgeons required 25% longer to become an Associate Professor (P = 0.017), 34% longer to become a Full Professor (P = 0.004), 37% longer for promotion from Assistant to Associate Professor (P < 0.001), and 32% longer from Assistant to Full Professor (P = 0.012). Promotion timelines did not vary by region or specialty among male and female cohorts. Linear regressions revealed that female neurosurgeons with more recent training completion experienced shorter time-to-promotion to Associate and Full Professor compared to females of earlier generations (P = 0.005 and 0.001, respectively), while male timelines remained stable. CONCLUSIONS This study identifies a significant delay in time-to-promotion for female neurosurgeons compared to their male counterparts. Investigation and standardization of promotion timelines are necessary to ensure meaningful representation gains from the increased number of women entering neurosurgical training.
Collapse
Affiliation(s)
| | | | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconness Medical Center, Boston, Massachusetts, USA
| | - Kristin Huntoon
- Department of Neurosurgery, MD Anderson Cancer Center, Houston, Texas, USA.
| |
Collapse
|
2
|
Stippler M, Blitz SE, Quinsey C, Limbrick D, Byrne R, Zipfel G, Selden NR. Active Teaching Techniques Using Virtual Didactics: Novel Experience From a National Neurosurgery Resident Course. J Surg Educ 2024; 81:312-318. [PMID: 38160110 DOI: 10.1016/j.jsurg.2023.11.006] [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] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 08/11/2023] [Accepted: 11/03/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE To investigate the attitudes of neurosurgery residents regarding active teaching techniques and virtual didactics based on a national neurosurgery resident sample. We also evaluated the relative cost and time commitment required for faculty participation in virtual versus in-person resident courses. DESIGN The Society of Neurological Surgeons (SNS) national junior resident courses (JRCs) were reformatted for active teaching in a virtual setting in 2020 due to the COVID-19 pandemic. We analyzed course evaluations from the virtual 2020 courses in comparison to the 2019 in-person SNS JRCs. We also compared course budgets and agendas from these courses to identify comparative costs and the time commitment for faculty participation using these 2 course models. SETTING Survey of nationwide participants in virtual junior resident courses. PARTICIPANTS A total of 122 residents from 80 ACGME neurosurgery residency training programs attended the 2020 virtual JRC. RESULTS The survey response rate of attendees was 36%. In-class engagement was thought to be good to great by 73% to 80% of the virtual learners. In-class activities and active learning techniques also were evaluated positively by 61% to 82% of respondents. Expenses were significantly lower for the virtual course, at $118 per course participant, than for the in-person course ($2722 per participant). There also was a 97.3% reduction of faculty hours and a 97.6% reduction of faculty cost for the virtual JRC compared to the in-person course. CONCLUSIONS Neurosurgeon residents embraced the active teaching techniques used to teach portions of the prepandemic JRCs in a virtual format. Other aspects of the course curriculum could not be replicated virtually. Virtual courses were dramatically less expensive to produce, used fewer faculty teachers and required less time per faculty member. The data from this study may inform the choice of active teaching techniques for other neurosurgery residency and continuing medical education courses to optimize learner engagement and participant satisfaction in the virtual setting. We recommend that the curriculum of in-person courses emphasize hands-on, experiential learning and professional enculturation that cannot be recreated in the virtual space. Curricular elements suitable to virtual learning should take advantage of lower costs, reduced faculty time requirements, and scalability. They should also utilize active teaching techniques to improve learner engagement.
Collapse
Affiliation(s)
- Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts.
| | | | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - David Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri; Department of Pediatrics, Washington University, St. Louis, Missouri
| | - Richard Byrne
- Department of Neurosurgery, Rush Medical College, Chicago, Illinois
| | - Greg Zipfel
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
3
|
Powers AY, Chang DC, Stippler M, Papavassiliou E, Moses ZB. Public health insurance, frailty, and lack of home support predict rehab discharge following elective anterior cervical discectomy and fusion. Spine J 2023; 23:1830-1837. [PMID: 37660894 DOI: 10.1016/j.spinee.2023.08.018] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/13/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) is a commonly-performed and generally well-tolerated procedure used to treat cervical disc herniation. Rarely, patients require discharge to inpatient rehab, leading to inconvenience for the patient and increased healthcare expenditure for the medical system. PURPOSE The objective of this study was to create an accurate and practical predictive model for, as well as delineate associated factors with, rehab discharge following elective ACDF. STUDY DESIGN This was a retrospective, single-center, cohort study. PATIENT SAMPLE Patients who underwent ACDF between 2012 and 2022 were included. Those with confounding diagnoses or who underwent concurrent, staged, or nonelective procedures were excluded. OUTCOME MEASURES Primary outcomes for this study included measurements of accuracy for predicting rehab discharge. Secondary outcomes included associations of variables with rehab discharge. METHODS Current Procedural Terminology codes identified patients. Charts were reviewed to obtain additional demographic and clinical characteristics on which an initial univariate analysis was performed. Two logistic regression and two machine learning models were trained and evaluated on the data using cross-validation. A multimodel logistic regression was implemented to analyze independent variable associations with rehab discharge. RESULTS A total of 466 patients were included in the study. The logistic regression model with minimum corrected Akaike information criterion score performed best overall, with the highest values for area under the receiver operating characteristic curve (0.83), Youden's J statistic (0.71), balanced accuracy (85.7%), sensitivity (90.3%), and positive predictive value (38.5%). Rehab discharge was associated with a modified frailty index of 2 (p=.007), lack of home support (p=.002), and having Medicare or Medicaid insurance (p=.007) after correction for multiple hypotheses. CONCLUSIONS Nonmedical social determinants of health, such as having public insurance or a lack of support at home, may play a role in rehab discharge following elective ACDF. In combination with the modified frailty index and other variables, these factors can be used to predict rehab discharge with high accuracy, improving the patient experience and reducing healthcare costs.
Collapse
Affiliation(s)
- Andrew Y Powers
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School. 110 Francis St, Suite 3B. Boston, MA 02215, USA.
| | - David C Chang
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School. 165 Cambridge St, Boston, MA 02114, USA
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School. 110 Francis St, Suite 3B. Boston, MA 02215, USA
| | - Efstathios Papavassiliou
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School. 110 Francis St, Suite 3B. Boston, MA 02215, USA
| | - Ziev B Moses
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School. 110 Francis St, Suite 3B. Boston, MA 02215, USA
| |
Collapse
|
4
|
Blitz SE, Mashouf LA, Nieves A, Matos J, Yaffe M, Davis RB, Alterman RL, Stippler M. Prevalence and Predictors of Inappropriate Antithrombotic Prescription in Patients Presenting With Traumatic Brain Injury. Neurosurgery 2023; 93:1019-1025. [PMID: 37235974 DOI: 10.1227/neu.0000000000002540] [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] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/29/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES A growing proportion of the US population is on antithrombotic therapy (AT), most significantly within the older subpopulation. Decision to use AT is a balance between the intended benefits and known bleeding risk, especially after traumatic brain injury (TBI). Preinjury inappropriate AT offers no benefit for the patient and also increases the risk of intracranial hemorrhage and worse outcome in the setting of TBI. Our objective was to examine the prevalence and predictors of inappropriate AT among patients presenting with TBI to a Level-1 Trauma Center. METHODS A retrospective chart review was performed on all patients with TBI and preinjury AT who presented to our institution between January 2016 and September 2020. Demographic and clinical data were collected. Appropriateness of AT was determined through established clinical guidelines. Clinical predictors were determined by logistic regression. RESULTS Of 141 included patients, 41.8% were female (n = 59) and the average age (mean ± SD) was 80.6 ± 9.9. The prescribed antithrombotic agents included aspirin (25.5%, n = 36), clopidogrel (22.7%, n = 32), warfarin (46.8%, n = 66), dabigatran (2.1%, n = 3), rivaroxaban (Janssen) (10.6%, n = 15), and apixaban (Bristol-Myers Squibb Co.) (18.4%, n = 26). The indications for AT were atrial fibrillation (66.7%, n = 94), venous thromboembolism (13.4%, n = 19), cardiac stent (8.5%, n = 12), and myocardial infarction/residual coronary disease (11.3%, n = 16). Inappropriate antithrombotic therapy use varied significantly by antithrombotic indication ( P < .001) with the highest rates seen with venous thromboembolism. Predictive factors also include age ( P = .005) with higher rates younger than 65 years and older than 85 years and female sex ( P = .049). Race and antithrombotic agent were not significant predictors. CONCLUSION Overall, 1 in 10 patients presenting with TBI were found to be on inappropriate AT. Our study is the first to describe this problem and warrants investigation into possible workflow interventions to prevent post-TBI continuation of inappropriate AT.
Collapse
Affiliation(s)
- Sarah E Blitz
- Harvard Medical School, Boston , Massachusetts , USA
| | | | - Amber Nieves
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
| | - Jason Matos
- Harvard Medical School, Boston , Massachusetts , USA
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
| | - Michael Yaffe
- Department of Acute Care Surgery, Beth Israel Deaconess Medical Center, Trauma and Surgical Critical Care, Boston , Massachusetts , USA
| | - Roger B Davis
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
| | - Ron L Alterman
- Harvard Medical School, Boston , Massachusetts , USA
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
| | - Martina Stippler
- Harvard Medical School, Boston , Massachusetts , USA
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston , Massachusetts , USA
| |
Collapse
|
5
|
Salih M, Young M, Garcia A, Stippler M, Papavassiliou E, Alterman RL, Thomas AJ, Taussky P, Moore J, Ogilvy CS. Outcome of Chronic Subdural Hematoma Intervention in Patients on Long-Term Antiplatelet Therapy-A Propensity Score Matched Analysis. Neurosurgery 2023; 93:586-591. [PMID: 36921243 DOI: 10.1227/neu.0000000000002452] [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] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/13/2023] [Indexed: 03/17/2023] Open
Abstract
BACKGROUND Patients presenting with chronic subdural hematomas (cSDHs) and on antiplatelet medications for various medical conditions often complicate surgical decision making. OBJECTIVE To evaluate risks of preprocedural and postprocedural antiplatelet use in patients with cSDHs. METHODS Patients with cSDH who were treated between January 2006 and February 2022 at a single institution with surgical intervention were identified. A propensity score matching analysis was then performed analyzing length of hospitalization, periprocedural complications, reintervention rate, rebleeding risk, and reintervention rates. RESULTS Preintervention, 178 patients were on long-term antiplatelet medication and 298 were not on any form of antiplatelet. Sixty matched pairs were included in the propensity score analysis. Postintervention, 88 patients were resumed on antiplatelet medication, whereas 388 patients did not have resumption of antiplatelets. Fifty-five pairs of matched patients were included in the postintervention propensity score analysis. No significant differences were found in length of hospitalization (7.8 ± 4.2 vs 6.8 ± 5.4, P = .25), procedural complications (3.3% vs 6.7%, P = .68), or reintervention during the same admission (3.3% vs 5%, P = 1). No significant differences were seen in recurrence rate (9.1% vs 10.9%, P = 1) or reintervention rate after discharge (7.3% vs 9.1%, P = 1) in the postintervention group. CONCLUSION Preintervention antiplatelet medications before cSDH treatment do not affect length of hospitalization, periprocedural complications, or reintervention. Resumption of antiplatelet medication after cSDH procedures does not increase the rebleeding risk or reintervention rate.
Collapse
Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Alfonso Garcia
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Efstathios Papavassiliou
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Ron L Alterman
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Ajith J Thomas
- Department of Neurological Surgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey , USA
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Justin Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston , Massachusetts , USA
| |
Collapse
|
6
|
Salih M, Salem MM, Ravina K, Stippler M, Papavassiliou E, Alterman RL, Thomas A, Moore JM, Ogilvy CS. 765 Outcome of Chronic Subdural Hematoma Management in Patients on Long Term Antiplatelet Therapy—A Propensity Score Matched Analysis. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_765] [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: 03/18/2023] Open
|
7
|
Salih M, Shutran M, Young M, Vega RA, Stippler M, Papavassiliou E, Alterman RL, Thomas A, Taussky P, Moore J, Ogilvy CS. Reduced recurrence of chronic subdural hematomas treated with open surgery followed by middle meningeal artery embolization compared to open surgery alone: a propensity score-matched analysis. J Neurosurg 2022:1-7. [PMID: 36681950 DOI: 10.3171/2022.11.jns222024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/09/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Middle meningeal artery embolization (MMAE) is an emerging endovascular treatment technique with proven promising results for chronic subdural hematomas (cSDHs). MMAE as an adjunct to open surgery is being utilized with the goal of preventing the recurrence of cSDH. However, the efficacy of MMAE following surgical evacuation of cSDH has not been clearly demonstrated. The authors sought to compare the outcomes of open surgery followed by MMAE versus open surgery alone. METHODS Patients who underwent surgical evacuation alone (open surgery-alone group) or MMAE along with open surgery for cSDH (adjunctive MMAE group) were identified at the authors' institution. Two balanced groups were obtained through propensity score matching. Primary outcomes included recurrence risk and reintervention rate. Secondary outcomes included decrease in hematoma size and modified Rankin Scale (mRS) score at last follow-up. Variables in the two groups were compared by use of the Mann-Whitney U-test, paired-sample t-test, and Fisher's exact test. RESULTS A total of 345 cases of open surgery alone and 52 cases of open surgery with adjunctive MMAE were identified. After control for subjective confounders, 146 patients treated with open surgery alone and 41 with adjunctive MMAE following open surgery with drain placement were included in the analysis. Before matching, the rebleeding risk and reintervention rate for open surgery trended higher in the open surgery alone than the open surgery plus MMAE group (14.4% vs 7.3%, p = 0.18; and 11.6% vs 4.9%, p = 0.17, respectively). No significant differences were seen in duration of radiographic or clinical follow-ups or decreases in hematoma size and mRS score at last follow-up. After one-to-one nearest neighbor propensity score matching, 26 pairs of cases were compared for outcomes. Rates of recurrence (7.7% vs 30.8%, p = 0.038) and overall reintervention (3.8% vs 23.1%, p = 0.049) after open surgery were found to be significantly lower in the adjunctive MMAE group than the open surgery-alone group. With one-to-many propensity score matching, 76 versus 37 cases were compared for open surgery alone versus adjunctive MMAE following open surgery. Similarly, the adjunctive MMAE group had significantly lower rates of recurrence (5.4% vs 19.7%, p = 0.037) and overall reintervention (2.7% vs 14.5%, p = 0.049). CONCLUSIONS Adjunctive MMAE following open surgery can lower the recurrence risks and reintervention rates for cSDH.
Collapse
Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Rafael A. Vega
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Efstathios Papavassiliou
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ron L. Alterman
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ajith Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Justin Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
8
|
Salih M, Young M, Shutran M, Stippler M, Papavassiliou E, Alterman RL, Thomas AJ, Taussky P, Moore J, Ogilvy CS. Effect of long-term anticoagulant therapy on the outcome of chronic subdural hematoma: a propensity score-matched analysis. J Neurosurg 2022:1-7. [PMID: 36681947 DOI: 10.3171/2022.11.jns222022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Chronic subdural hematomas (cSDHs) are particularly common in older adults who have increased risk of falls and the conditions that require anticoagulants (ACs). In such cases, clinicians are often left with the dilemma of co-managing the cSDH and the ongoing need for ACs. METHODS Patients who underwent surgical management for cSDH at the authors' institution between January 2006 and June 2022 were identified. Propensity score-matched analysis was used to obtain a balance in patients who were on ACs before the procedure versus those who were not, and in patients who were on ACs postprocedure versus those who were not. Length of hospitalization, periprocedural complications, reintervention rate during the same admission, rebleeding risk, and reintervention rates after discharge were compared. RESULTS In total, 104 patients were on long-term ACs before the procedure, whereas 372 were not. After matching, 55 pairs were included in the analysis. Postprocedure, 74 patients were started on long-term ACs; the rest were not. A total of 49 patients in each group were then included in the analysis after matching. Comparing the preprocedure AC group with the non-AC group, no significant differences were found in length of hospitalization (8.5 ± 6.7 days vs 8.1 ± 7.7 days, p = 0.75), periprocedural complications (7.3% vs 7.3%, p > 0.99), or reintervention during the same admission (1.8% vs 5.5%, p = 0.31). In the comparison of postprocedure AC and non-AC groups, no significant differences were seen in recurrence rate (8.2% vs 14.3%, p = 0.52), reintervention rate after discharge (4.1% vs 14.3%, p = 0.16), or disability (i.e., mRS ≤ 2; 83.7% vs 89.8%, p = 0.55). CONCLUSIONS Being treated with long-term ACs before cSDH procedures does not affect length of hospitalization, periprocedural complications, or reintervention during the same admission. Similarly, administration of long-term ACs after a procedure for cSDH does not increase rebleeding risk or reintervention rate. Patients who are on long-term ACs can have similar interventions to those who are not on ACs. In addition, it is safe to restart patients on AC agents in a 7- to 14-day window after admission for cSDH with or without acute/subacute components.
Collapse
Affiliation(s)
- Mira Salih
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael Young
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Max Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Efstathios Papavassiliou
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ron L. Alterman
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Ajith J. Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Philipp Taussky
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Justin Moore
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| | - Christopher S. Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center Brain Aneurysm Institute, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
9
|
Hoffman C, Härtl R, Shlobin NA, Tshimbombu TN, Elbabaa SK, Haglund MM, Rubiano AM, Dewan MC, Stippler M, Mahmud MR, Barthélemy EJ, Griswold DP, Wohns R, Shabani HK, Rocque B, Sandberg DI, Lafuente J, Dempsey R, Rosseau G. Future Directions for Global Clinical Neurosurgical Training: Challenges and Opportunities. World Neurosurg 2022; 166:e404-e418. [PMID: 35868506 DOI: 10.1016/j.wneu.2022.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Expanded access to training opportunities is necessary to address 5 million essential neurosurgical cases not performed annually, nearly all in low- and middle-income countries. To target this critical neurosurgical workforce issue and advance positive collaborations, a summit (Global Neurosurgery 2019: A Practical Symposium) was designed to assemble stakeholders in global neurosurgical clinical education to discuss innovative platforms for clinical neurosurgery fellowships. METHODS The Global Neurosurgery Education Summit was held in November 2021, with 30 presentations from directors and trainees in existing global neurosurgical clinical fellowships. Presenters were selected based on chain referral sampling from suggestions made primarily from young neurosurgeons in low- and middle-income countries. Presentations focused on the perspectives of hosts, local champions, and trainees on clinical global neurosurgery fellowships and virtual learning resources. This conference sought to identify factors for success in overcoming barriers to improving access, equity, throughput, and quality of clinical global neurosurgery fellowships. A preconference survey was disseminated to attendees. RESULTS Presentations included in-country training courses, twinning programs, provision of surgical laboratories and resources, existing virtual educational resources, and virtual teaching technologies, with reference to their applicability to hybrid training fellowships. Virtual learning resources developed during the coronavirus disease 2019 pandemic and high-fidelity surgical simulators were presented, some for the first time to this audience. CONCLUSIONS The summit provided a forum for discussion of challenges and opportunities for developing a collaborative consortium capable of designing a pilot program for efficient, sustainable, accessible, and affordable clinical neurosurgery fellowship models for the future.
Collapse
Affiliation(s)
- Caitlin Hoffman
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Roger Härtl
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tshibambe N Tshimbombu
- Department of Neurosurgery, Geisel School of Medicine, Dartmouth University, Hannover, New Hampshire, USA
| | - Samer K Elbabaa
- Section of Pediatric and Fetal Neurosurgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Michael M Haglund
- Division of Global Neurosurgery and Neurology and Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Andrés M Rubiano
- Neurosciences Institute, Neurosurgery Service, El Bosque University, El Bosque Clinic, MEDITECH-INUB Research Group, Bogotá, Colombia
| | - Michael C Dewan
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammad Raji Mahmud
- Neurosurgery Unit, Department of Surgery, Ahmadu Bello University, Zaria Kaduna, Nigeria; Division of Neurosurgery, Department of Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York, USA; Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; School of Medicine, Stanford School of Medicine, Stanford, California, USA
| | - Ernest J Barthélemy
- Division of Neurosurgery, Department of Surgery, SUNY Downstate Health Sciences University, Brooklyn, New York, USA
| | - Dylan P Griswold
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK; School of Medicine, Stanford School of Medicine, Stanford, California, USA
| | | | - Hamisi K Shabani
- Department of Neurosurgery, Muhimbili Orthopaedic Institute, Dar es Salaam, Tanzania
| | - Brandon Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - David I Sandberg
- Division of Pediatric Neurosurgery, University of Texas Health Sciences Center, McGovern Medical School and Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Jesús Lafuente
- Department of Neurosurgery, Hospital Universitario del Mar, Barcelona, Spain
| | - Robert Dempsey
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Gail Rosseau
- Department of Neurological Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| |
Collapse
|
10
|
Hoffman SE, Vega RA, Stippler M. Teaching through the screen: a toolbox for creating a virtual neurosurgical subinternship program. Neurosurg Focus 2022; 53:E7. [DOI: 10.3171/2022.5.focus22171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The coronavirus disease 2019 (COVID-19) pandemic disrupted the landscape of traditional neurosurgical subinternships, ramifications of which persist to this day. The outright cancellation of in-person subinternships in 2020 presented not only a challenge to both applicants and programs, but also an opportunity to establish an effective and efficient platform for virtual neurosurgical training. To address this need, the authors designed and trialed a novel virtual neurosurgical subinternship (Virtual Sub-I).
METHODS
The weeklong, case-based Virtual Sub-I program combined flipped-classroom and active learning approaches. Students worked in small groups to discuss neurosurgical cases. Faculty and residents offered personalized mentorship sessions to participants. Surveys were used to assess students’ experience with the authors’ subinternship program, consistent with level 1 of the Kirkpatrick model.
RESULTS
A total of 132 students applied from both international and American medical schools. The final cohort comprised 27 students, of whom 8 (30%) were female and 19 (70%) were male. Students characterized the subinternship as “interactive,” “educational,” and “engaging.” One hundred percent of survey respondents were “very likely” to recommend the Virtual Sub-I to their peers. Faculty involved in the Virtual Sub-I stated that the program allowed them to determine the fit of participating medical students for their neurosurgery residency program, and that information gathered from the Virtual Sub-I had the potential to influence their ranking decisions.
CONCLUSIONS
The Virtual Sub-I recapitulates the educational and interpersonal benefits of the traditional subinternship experience and can serve as a prototype for future virtual surgical education endeavors. Furthermore, the Virtual Sub-I presents a more equitable platform for introducing medical students across the undergraduate medical education spectrum to neurosurgical education and mentorship.
Collapse
Affiliation(s)
| | - Rafael A. Vega
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
11
|
Mackel C, Rosenberg H, Varma H, Vega R, Stippler M. Cerebral Metastases in Appendiceal Cancer: Comprehensive Review and Report of Rare Medullary Carcinoma Histology. Brain Tumor Res Treat 2022; 10:200-205. [PMID: 35929119 PMCID: PMC9353166 DOI: 10.14791/btrt.2022.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/28/2022] [Accepted: 07/11/2022] [Indexed: 11/20/2022] Open
Abstract
Appendiceal cancer is an extremely rare malignancy, and its metastatic spread to the brain is even more unusual. We describe a 47-year-old female who presented with a rare cerebral appendiceal carcinoma metastasis, a case that is further remarkable for representing the first histologic diagnosis of primary medullary carcinoma in the appendix. Based on a comprehensive review of the English literature using PubMed, Embase, and Google Scholar, only six other cases of cerebral appendiceal metastases have been described.
Collapse
Affiliation(s)
- Charles Mackel
- Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
| | - Harry Rosenberg
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Hemant Varma
- Department of Pathology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Rafael Vega
- Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Mackel CE, Alterman RL, Buss MK, Reynolds RM, Fox WC, Spiotta AM, Davis RB, Stippler M. Moral Distress and Moral Injury Among Attending Neurosurgeons: A National Survey. Neurosurgery 2022; 91:59-65. [PMID: 35319531 PMCID: PMC9514751 DOI: 10.1227/neu.0000000000001921] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/26/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND "Moral distress" describes the psychological strain a provider faces when unable to uphold professional values because of external constraints. Recurrent or intense moral distress risks moral injury, burnout, and physician attrition but has not been systematically studied among neurosurgeons. OBJECTIVE To develop a unique instrument to test moral distress among neurosurgeons, evaluate the frequency and intensity of scenarios that may elicit moral distress and injury, and determine their impact on neurosurgical burnout and turnover. METHODS An online survey investigating moral distress, burnout, and practice patterns was emailed to attending neurosurgeon members of the Congress of Neurological Surgeons. Moral distress was evaluated through a novel survey designed for neurosurgical practice. RESULTS A total of 173 neurosurgeons completed the survey. Half of neurosurgeons (47.7%) reported significant moral distress within the past year. The most common cause was managing critical patients lacking a clear treatment plan; the most intense distress was pressure from patient families to perform futile surgery. Multivariable analysis identified burnout and performing ≥2 futile surgeries per year as predictors of distress (P < .001). Moral distress led 9.8% of neurosurgeons to leave a position and 26.6% to contemplate leaving. The novel moral distress survey demonstrated excellent internal consistency (Cronbach alpha = 0.89). CONCLUSION We developed a reliable survey assessing neurosurgical moral distress. Nearly, half of neurosurgeons suffered moral distress within the past year, most intensely from external pressure to perform futile surgery. Moral distress correlated with burnout risk caused 10% of neurosurgeons to leave a position and a quarter to consider leaving.
Collapse
Affiliation(s)
- Charles E. Mackel
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA;
| | - Ron L. Alterman
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA;
| | - Mary K. Buss
- Section of Palliative Care, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA;
| | - Renée M. Reynolds
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA;
| | - W. Christopher Fox
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Florida, USA;
| | - Alejandro M. Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA;
| | - Roger B. Davis
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA;
| |
Collapse
|
13
|
Hawryluk GW, Selph S, Lumba-Brown A, Totten AM, Ghajar J, Aarabi B, Ecklund J, Shackelford S, Adams B, Adelson D, Armonda RA, Benjamin J, Boone D, Brody D, Dengler B, Figaji A, Grant G, Harris O, Hoffer A, Kitigawa R, Latham K, Neal C, Okonkwo DO, Pannell D, Rosenfeld JV, Rosenthal G, Rubiano A, Stein DM, Stippler M, Talbot M, Valadka A, Wright DW, Davis S, Bell R. Rationale and Methods for Updated Guidelines for the Management of Penetrating Traumatic Brain Injury. Neurotrauma Rep 2022; 3:240-247. [PMID: 35919507 PMCID: PMC9279118 DOI: 10.1089/neur.2022.0008] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and healthcare costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries. A preliminary literature search revealed a need for updated guidelines, supported by the Brain Trauma Foundation. Methodologists experienced in TBI guidelines were recruited to support project development alongside two cochairs and a diverse steering committee. An expert multi-disciplinary workgroup was established and vetted to inform key clinical questions, to perform an evidence review and the development of recommendations relevant to pTBI. The methodological approach for the project was finalized. The development of up-to-date evidence- and consensus-based clinical care guidelines and algorithms for pTBI will provide critical guidance to care providers in the pre-hospital and emergent, medical, and surgical settings.
Collapse
Affiliation(s)
| | - Shelley Selph
- Department of Medical Informatics and Clinical Epidemiology, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Angela Lumba-Brown
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - Annette M. Totten
- Department of Medical Informatics and Clinical Epidemiology, Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University, Portland, Oregon, USA
| | - Jamshid Ghajar
- Stanford Neuroscience Health Center, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - Bizhan Aarabi
- University of Maryland Neurosurgery Associates, R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - James Ecklund
- Inova Neuroscience and Spine Institute, Fairfax, Virginia, USA
| | - Stacy Shackelford
- Joint Trauma System, Department of Defense, Center of Excellence for Trauma, Baltimore, Maryland, USA
| | - Britton Adams
- Independent Duty Medical Technician (IDMT), Hurlburt Field, Florida, USA
| | - David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital, University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Rocco A. Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - John Benjamin
- Anaethesia and Critical Care, Uniformed Services University, Bethesda, Maryland, USA
| | - Darrell Boone
- Department of Surgery, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
| | - David Brody
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Bradley Dengler
- Department of Neurosurgery, Uniformed Services University, Bethesda, Maryland, USA
| | - Anthony Figaji
- Department of Neurosurgery, University of Cape Town, Cape Town, Western Cape, South Africa
| | - Gerald Grant
- Department of Neurosurgery, Duke University, Raleigh, North Carolina, USA
| | - Odette Harris
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Palo Alto, California, USA
| | - Alan Hoffer
- Department of Neurosurgery, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ryan Kitigawa
- McGovern Medical School, University of Texas, Houston, Texas, USA
| | - Kerry Latham
- Adult Outpatient Behavioral Health, Bethesda, Maryland, USA
| | - Christopher Neal
- Department of Neurosurgery Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dylan Pannell
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Guy Rosenthal
- Hadassah University Medical Center, Jerusalem, Israel
| | - Andres Rubiano
- INUB-Meditech Research Group, Neuroscience Institute, Universidad El Bosque, Bogota, Colombia
| | - Deborah M. Stein
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max Talbot
- Royal Canadian Medical Service, Canadian Armed Forces, Canadian Forces Base Borden, Ontario, Canada
| | - Alex Valadka
- Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - David W. Wright
- Department of Emergency Medicine, Emory University, Atlanta, Georgia, USA
| | - Shelton Davis
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Randy Bell
- Department of Neurosurgery, Uniformed Services University, Bethesda, Maryland, USA
| |
Collapse
|
14
|
Plonsker JH, Benzil D, Air EL, Woodrow S, Stippler M, Ben-Haim S. Gender Equality in Neurosurgery and Strategic Goals Toward a More Balanced Workforce. Neurosurgery 2022; 90:642-647. [PMID: 35311744 DOI: 10.1227/neu.0000000000001910] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022] Open
Abstract
The Women in Neurosurgery (WINS) and the American Association of Neurological Surgeons published a white paper in 2008 setting an ambitious goal for women to comprise 20% of neurosurgery residents by 2012 and 20% of practicing neurosurgeons by 2020. Although there has been steady progress, we have fallen short of these benchmarks. We take this opportunity to look back at the accomplishments made over the past decade and provide an update on our present status. We evaluate current barriers toward progress and propose new goals, highlighting the systemic changes necessary to accomplish them. We propose the following updated recommendations to recruit and retain diverse talent into the neurosurgical workforce. (1) Neurosurgical departments and societies should provide diverse, early formal mentorship opportunities for medical students, residents, and junior faculty members. (2) Parental leave policies must be delineated, promoted, and enforced for all neurosurgeons, with greater awareness of internal discrimination and normalization of the discussion surrounding this topic. (3) We need to strive for compensation equity, with transparency in compensation mechanisms and regular assessment of compensation metrics. (4) Departments and institutions must have a zero-tolerance policy for sexual harassment and discrimination and establish a safe reporting structure. Finally, we propose attainable benchmarks toward achieving gender balance in the neurosurgical workforce, with a goal for women to comprise 30% of the entering residency class by 2030 and to comprise 30% of practicing neurosurgeons by 2038. We hope that this will guide further progress toward our future of building a balanced workforce.
Collapse
Affiliation(s)
| | - Deborah Benzil
- Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ellen L Air
- Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan, USA
| | - Sarah Woodrow
- Department of Neurosurgery, Cleveland Clinic Akron General, Akron, Ohio, USA
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sharona Ben-Haim
- Department of Neurosurgery, UC San Diego, San Diego, California, USA
| |
Collapse
|
15
|
Mashouf LA, Nieves A, Matos J, Yaffe M, Stippler M. 323 Prevalence and Predictors of Inappropriate Pre-injury Antithrombotic Use in Patients Presenting with TBI. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_323] [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: 11/18/2022] Open
|
16
|
Enriquez-Marulanda A, Gomez-Paz S, Salem MM, Mallick A, Arle JE, Stippler M, Papavassiliou E, Alterman RL, Ogilvy CS, Moore JM, Thomas AJ. 801 Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_801] [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
|
17
|
Mackel CE, Alterman RL, Stippler M. 120 Moral Distress Among Attending Neurosurgeons: A National Survey. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_120] [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
|
18
|
Plonsker JH, Benzil DL, Air EL, Woodrow S, Stippler M, Ben-Haim S. 826 Gender Equality in Neurosurgery and Strategic Goals Towards a More Balanced Workforce. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_826] [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
|
19
|
Uhlmann EJ, Rabinovsky R, Varma H, El Fatimy R, Kasper EM, Moore JM, Vega RA, Thomas AJ, Alterman RL, Stippler M, Anderson MP, Uhlmann EN, Kipper FC, Krichevsky AM. Tumor-Derived Cell Culture Model for the Investigation of Meningioma Biology. J Neuropathol Exp Neurol 2021; 80:1117-1124. [PMID: 34850056 PMCID: PMC8716066 DOI: 10.1093/jnen/nlab111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Meningioma is the most common primary central nervous system tumor. Although mostly nonmalignant, meningioma can cause serious complications by mass effect and vasogenic edema. While surgery and radiation improve outcomes, not all cases can be treated due to eloquent location. Presently no medical treatment is available to slow meningioma growth owing to incomplete understanding of the underlying pathology, which in turn is due to the lack of high-fidelity tissue culture and animal models. We propose a simple and rapid method for the establishment of meningioma tumor-derived primary cultures. These cells can be maintained in culture for a limited time in serum-free media as spheres and form adherent cultures in the presence of 4% fetal calf serum. Many of the tissue samples show expression of the lineage marker PDG2S, which is typically retained in matched cultured cells, suggesting the presence of cells of arachnoid origin. Furthermore, nonarachnoid cells including vascular endothelial cells are also present in the cultures in addition to arachnoid cells, potentially providing a more accurate tumor cell microenvironment, and thus making the model more relevant for meningioma research and high-throughput drug screening.
Collapse
Affiliation(s)
- Erik J Uhlmann
- From the Department of Neurology, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rosalia Rabinovsky
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hemant Varma
- Department of Pathology, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rachid El Fatimy
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ekkehard M Kasper
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rafael A Vega
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ronald L Alterman
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew P Anderson
- Department of Pathology, Beth Israel Deaconess Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Erik N Uhlmann
- Department of Surgery, Hamilton General Hospital, Hamilton, Ontario, Canada.,Khoury College of Computer Sciences, Northeastern University, Boston, Massachusetts, USA
| | - Franciela C Kipper
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Anna M Krichevsky
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
20
|
Stippler M, Keith S, Nelton EB, Parsons CS, Singleton J, Bilello LA, Tibbles CD, Davis RB, Edlow JA, Rosen CL. Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa504_s112] [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: 11/14/2022] Open
|
21
|
Mackel CE, Nelton EB, Reynolds RM, Fox WC, Spiotta AM, Stippler M. A Scoping Review of Burnout in Neurosurgery. Neurosurgery 2021; 88:942-954. [PMID: 33471896 DOI: 10.1093/neuros/nyaa564] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 08/12/2020] [Accepted: 11/04/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Burnout is a negative workplace syndrome of emotional exhaustion, cynicism, and perceived professional inefficacy that risks the patient-provider relationship, patient care, and physician well-being. OBJECTIVE To assimilate the neurosurgical burnout literature in order to classify burnout among domestic and international neurosurgeons and trainees, identify contributory factors, and appraise the impact of wellness programs. METHODS A scoping review identified the available literature, which was reviewed for key factors related to burnout among neurosurgeons. Two researchers queried PubMed, Embase, Google Scholar, Cochrane, and Web of Science for articles on burnout in neurosurgery and reduced 1610 results to 32 articles. RESULTS A total of 32 studies examined burnout in neurosurgery. A total of 26 studies examined prevalence and 8 studies detailed impact of wellness programs. All were published after 2011. Burnout prevalence was measured mostly through the Maslach Burnout Inventory (n = 21). In 4 studies, participants defined their own understanding of "burnout." Domestically, burnout prevalence was 11.2% to 67% among residents and 15% to 57% among attendings. Among trainees, poor operative experience, poor faculty relationships, and social stressors were burnout risks but not age, sex, or marital status. Among attendings, the literature identified financial or legal concerns, lack of intellectual stimulation, and poor work-life balance as risks. The impact of wellness programs on trainees is unclear but group exercises may offer the most benefit. CONCLUSION Noticeable methodological differences in studies on trainee and attending burnout contribute to a wide range of neurosurgery burnout estimates and yield significant knowledge gaps. Environment may have greater impact on trainee burnout than demographics. Wellness programs should emphasize solidarity.
Collapse
Affiliation(s)
- Charles E Mackel
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Emmalin B Nelton
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Renée M Reynolds
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | | | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
22
|
Enriquez-Marulanda A, Gomez-Paz S, Salem MM, Mallick A, Motiei-Langroudi R, Arle JE, Stippler M, Papavassiliou E, Alterman RL, Ogilvy CS, Moore JM, Thomas AJ. Middle Meningeal Artery Embolization Versus Conventional Treatment of Chronic Subdural Hematomas. Neurosurgery 2021; 89:486-495. [PMID: 34171921 DOI: 10.1093/neuros/nyab192] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 09/27/2020] [Accepted: 04/03/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Middle meningeal artery (MMA) embolization is an emerging minimally invasive endovascular technique for chronic subdural hematoma (cSDH). Currently, limited literature exists on its safety and efficacy compared with conventional treatment (open-surgical-evacuation-only). OBJECTIVE To compare MMA embolization to conventional treatment. METHODS Retrospective analysis of patients with cSDHs treated with MMA embolization in a single center from 2018 to 2019 was performed. Comparisons were made with a historical conventional treatment cohort from 2006 to 2016. Propensity score matching analysis was used to assemble a balanced group of subjects. RESULTS A total of 357 conventionally treated cSDH and 45 with MMA embolization were included. After balancing with propensity score matching, a total of 25 pairs of cSDH were analyzed. Comparing the embolization with the conventional treatment group yielded no significant differences in complications (4% vs 4%; P > .99), clinical improvement (82.6% vs 83.3%; P = .95), cSDH recurrence (4.3% vs 21.7%; P = .08), overall re-intervention rates (12% vs 24%; P = .26), modified Rankin scale >2 on last follow-up (17.4% vs 32%; P = .24), as well as mortality (0% vs 12%; P = .09). Radiographic improvement at last follow-up was significantly higher in the open surgery cohort (73.9% vs 95.6%; P = .04). However, there was a trend for lengthier last follow-up for the historical cohort (72 vs 104 d; P = .07). CONCLUSION There was a trend for lower recurrence and mortality rates in the embolization era cohort. There were significantly higher radiological improvement rates on last follow-up in the surgical only cohort era. There were no significant differences in complications and clinical improvement.
Collapse
Affiliation(s)
| | - Santiago Gomez-Paz
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Akashleena Mallick
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - J E Arle
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Martina Stippler
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Efstathios Papavassiliou
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron L Alterman
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher S Ogilvy
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin M Moore
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Neurosurgery Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Stippler M, Keith S, Nelton EB, Parsons CS, Singleton J, Bilello LA, Tibbles CD, Davis RB, Edlow JA, Rosen CL. Pathway-Based Reduction of Repeat Head Computed Tomography for Patients With Complicated Mild Traumatic Brain Injury: Implementation and Outcomes. Neurosurgery 2021; 88:773-778. [PMID: 33469647 PMCID: PMC7956047 DOI: 10.1093/neuros/nyaa504] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/14/2020] [Accepted: 09/21/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Routine follow-up head imaging in complicated mild traumatic brain injury (cmTBI) patients has not been shown to alter treatment, improve outcomes, or identify patients in need of neurosurgical intervention. We developed a follow-up head computed tomography (CT) triage algorithm for cmTBI patients to decrease the number of routine follow-up head CT scans obtained in this population. OBJECTIVE To report our experience with protocol implications and patient outcome. METHODS Data on all cmTBI patients presenting from July 1, 2018 to June 31, 2019, to our level 1, tertiary, academic medical center were collected prospectively and analyzed retrospectively. Descriptive analysis was performed. RESULTS Of the 178 patients enrolled, 52 (29%) received a follow-up head CT. A total of 27 patients (15%) were scanned because of initial presentation and triaged to the group to receive a routine follow-up head CT. A total of 151 patients (85%) were triaged to the group without routine follow-up head CT scan. Protocol adherence was 89% with 17 violations. CONCLUSION Utilizing this protocol, we were able to safely decrease the use of routine follow-up head CT scans in cmTBI patients by 71% without any missed injuries or delayed surgery. Adoption of the protocol was high among all services managing TBI patients.
Collapse
Affiliation(s)
- Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Stacey Keith
- Division of Acute Care, Trauma, and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Emmalin B Nelton
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Charles S Parsons
- Division of Acute Care, Trauma, and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jennifer Singleton
- Department of Emergency Medicine, UC Health Highlands Ranch Hospital, University of Colorado School of Medicine, Aurora, Colorado
| | - Leslie A Bilello
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carrie D Tibbles
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Roger B Davis
- Division of General Medicine, Department of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Carlo L Rosen
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
24
|
Feng R, Hoffman SE, Wagner K, Ullman JS, Stippler M, Germano IM. Women Neurosurgeons in Academic and Other Leadership Positions in the United States. World Neurosurg 2020; 147:80-88. [PMID: 33358734 DOI: 10.1016/j.wneu.2020.12.069] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 11/18/2020] [Revised: 12/11/2020] [Accepted: 12/12/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To provide the status of women neurosurgeons (WNS) in academic faculty and/or leadership positions in neurosurgery in the United States. METHODS Neurosurgery academic programs were defined as having an Accreditation Council for Graduate Medical Education (ACGME) neurosurgery residency program (NSRP). Using a Google search, gender, academic rank, postgraduate degrees, academic and clinical titles, and subspecialty were recorded for each neurosurgery faculty. Officer gender was recorded for the top 7 neurosurgery U.S. organizations, 7 subspecialty sections, and 50 state neurosurgical societies. RESULTS WNS were faculty at 77% (89/115) of ACGME NSRPs and constituted 10% of the workforce (186/1773). WNS residents were in 92% of ACGME NSRPs and constituted 19% of the workforce (293/1515). Two NSRPs (8%) had neither WNS faculty nor WNS residents. Of NSRPs without WNS faculty, 52% (13/25) had a faculty size >10. WNS accounted for 3% of NSRP chair positions. Academic rank of WNS faculty was lower than academic rank of men neurosurgeons faculty (P < 0.05). WNS faculty had a higher number of postgraduate degrees (P < 0.05). Pediatrics was the most common subspecialty (30%) among WNS. Over time, WNS held 1% of the leadership positions within the top 7 U.S. neurosurgery organizations and 7% within the 7 subspecialty sections. Over the past 20 years, 28% (14/50) of U.S. state neurosurgical societies had WNS serve as president. CONCLUSIONS In 2020, the gender gap for U.S. WNS faculty and residents still exists. By providing informed benchmarks, our study might help neurosurgery organizations, medical school leadership, hiring committees, editors, and conference speakers to plan their next steps.
Collapse
Affiliation(s)
- Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Katherine Wagner
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jamie S Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
25
|
Penumaka A, Stippler M, Mackel CE, Filippidis A, Powers A. Establishing an Interactive Web-based Neurosurgery Resident Curriculum. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_178] [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: 11/12/2022] Open
|
26
|
Stippler M, Nelton E, Keith S, Rosen C. Protocol to Reduce Routine Follow-up Head Imaging in Complicated Mild Traumatic Brain Injury. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_479] [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: 11/14/2022] Open
|
27
|
Wagner KE, Binyamin TR, Colley P, Chiluwal AK, Harrop JS, Hawryluk GW, Hickman ZL, Margetis K, Rymarczuk GN, Stippler M, Ullman JS. Trauma. Oper Neurosurg (Hagerstown) 2020; 17:S45-S75. [PMID: 31099847 DOI: 10.1093/ons/opz089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Tamar R Binyamin
- Department of Neurosurgery, University of California Davis Medical Center, Sacramento, California
| | - Patrick Colley
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Amrit K Chiluwal
- Department of Neurosurgery, Northwell Health, Manhasset, New York
| | - James S Harrop
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | - Zachary L Hickman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Konstantinos Margetis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - George N Rymarczuk
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.,Division of Neurosurgery, Walter Reed Medical Center, Bethesda, Maryland
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Jamie S Ullman
- Department of Neurosurgery, Northwell Health, Manhasset, New York
| |
Collapse
|
28
|
Atesok K, Stippler M, Striano BM, Xiong G, Lindsey M, Cappellucci E, Psilos A, Richter S, Heffernan MJ, Theiss S, Papavassiliou E. Bisphosphonates and parathyroid hormone analogs for improving bone quality in spinal fusion: State of evidence. Orthop Rev (Pavia) 2020; 12:8590. [PMID: 32922704 PMCID: PMC7461648 DOI: 10.4081/or.2020.8590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 05/01/2020] [Indexed: 11/23/2022] Open
Abstract
Spinal fusion is among the most commonly performed surgical procedures for elderly patients with spinal disorders - including degenerative disc disease with spondylolisthesis, deformities, and trauma. With the large increase in the aging population and the prevalence of osteoporosis, the number of elderly osteoporotic patients needing spinal fusion has risen dramatically. Due to reduced bone quality, postoperative complications such as implant failures, fractures, post-junctional kyphosis, and pseudarthrosis are more commonly seen after spinal fusion in osteoporotic patients. Therefore, pharmacologic treatment strategies to improve bone quality are commonly pursued in osteoporotic cases before conducting spinal fusions. The two most commonly used pharmacotherapeutics are bisphosphonates and parathyroid hormone (PTH) analogs. Evidence indicates that using bisphosphonates and PTH analogs, alone or in combination, in osteoporotic patients undergoing spinal fusion, decreases complication rates and improves clinical outcomes. Further studies are needed to develop guidelines for the administration of bisphosphonates and PTH analogs in osteoporotic spinal fusion patients in terms of treatment duration, potential benefits of sequential use, and the selection of either therapeutic agents based on patient characteristics.
Collapse
Affiliation(s)
- Kivanc Atesok
- Children's Hospital New Orleans/LSU Health Science Center, New Orleans, LA.,Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Neurosurgery
| | - Martina Stippler
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Neurosurgery
| | | | - Grace Xiong
- Harvard Combined Orthopaedic Residency Program, Boston, MA
| | | | - Elysia Cappellucci
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Neurosurgery
| | - Alexandra Psilos
- Children's Hospital New Orleans/LSU Health Science Center, New Orleans, LA
| | - Sven Richter
- Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Neurosurgery
| | | | - Steven Theiss
- University of Alabama at Birmingham, Department of Orthopaedic Surgery, Birmingham, AL, USA
| | | |
Collapse
|
29
|
Motiei-Langroudi R, Alterman RL, Stippler M, Phan K, Alturki AY, Papavassiliou E, Kasper EM, Arle J, Ogilvy CS, Thomas AJ. Factors influencing the presence of hemiparesis in chronic subdural hematoma. J Neurosurg 2020; 131:1926-1930. [PMID: 30641839 DOI: 10.3171/2018.8.jns18579] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 03/10/2018] [Accepted: 08/28/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronic subdural hematoma (CSDH) has a variety of clinical presentations, including hemiparesis. Hemiparesis is of the utmost importance because it is one of the major indications for surgical intervention and influences outcome. In the current study, the authors intended to identify factors influencing the presence of hemiparesis in CSDH patients and to determine the threshold value of hematoma thickness and midline shift for development of hemiparesis. METHODS The authors retrospectively reviewed 325 patients (266 with unilateral and 59 with bilateral hematomas) with CSDH who underwent surgical evacuation, regardless of presence or absence of hemiparesis. RESULTS In univariate analysis, hematoma loculation, age, hematoma maximal thickness, and midline shift were significantly associated with hemiparesis. Moreover, patients with unilateral hematomas had a higher rate of hemiparesis than patients with bilateral hematomas. Sex, trauma history, anticoagulant and antiplatelet drug use, presence of comorbidities, Glasgow Coma Scale score, hematoma density characteristics on CT scan, and hematoma signal intensity on T1- and T2-weighted MRI were not associated with hemiparesis. In multivariate analysis, the presence of loculation and hematoma laterality (unilateral vs bilateral) influenced hemiparesis. For unilateral hematomas, maximal hematoma thickness of 19.8 mm and midline shift of 6.4 mm were associated with a 50% probability of hemiparesis. For bilateral hematomas, 29.0 mm of maximal hematoma thickness and 6.8 mm of shift were associated with a 50% probability of hemiparesis. CONCLUSIONS Presence of loculations, unilateral hematomas, older patient age, hematoma maximal thickness, and midline shift were associated with a higher rate of hemiparesis in CSDH patients. Moreover, 19.8 mm of hematoma thickness and 6.4 mm of midline shift were associated with a 50% probability of hemiparesis in patients with unilateral hematomas.
Collapse
Affiliation(s)
- Rouzbeh Motiei-Langroudi
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,2Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ron L Alterman
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kevin Phan
- 3University of Sydney Westmead Clinical School, Westmead, New South Wales, Australia
| | - Abdulrahman Y Alturki
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.,4Department of Neurosurgery, The National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia; and
| | - Efstathios Papavassiliou
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ekkehard M Kasper
- 5Division of Neurosurgery, Hamilton General Hospital, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Jeffrey Arle
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ajith J Thomas
- 1Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
30
|
Corley J, Kim E, Philips CA, Stippler M, Parr AM, Sweet J, Rosseau G. One hundred years of neurosurgery: contributions of American women. J Neurosurg 2020:1-6. [PMID: 32059180 DOI: 10.3171/2019.12.jns192878] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/03/2019] [Indexed: 11/06/2022]
Abstract
The end of the first 100 years of any endeavor is an appropriate time to look back and peer forward. As neurosurgery celebrates its 1st century as a specialty, the increasing role of women neurosurgeons is a major theme. This article documents the early women pioneers in neurosurgery. The contributions of these trailblazers to the origins, academics, and professional organizations of neurosurgery are highlighted. The formation of Women in Neurosurgery in 1989 is described, as is the important role this organization has played in introducing and promoting talented women in the profession. Contributions of women neurosurgeons to academic medicine and society as a whole are briefly highlighted. Contemporary efforts and initiatives indicate future directions in which women may lead neurosurgery in its 2nd century.
Collapse
Affiliation(s)
- Jacquelyn Corley
- 1Gender Equity Initiative in Global Surgery, Boston, Massachusetts.,2Department of Neurological Surgery, Duke University Hospital, Durham, North Carolina
| | - Eliana Kim
- 1Gender Equity Initiative in Global Surgery, Boston, Massachusetts.,3University of California, San Francisco School of Medicine, San Francisco, California
| | - Chris Ann Philips
- 4American Association of Neurological Surgeons, Rolling Meadows, Illinois
| | - Martina Stippler
- 5Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ann M Parr
- 6Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Jennifer Sweet
- 7Department of Neurosurgery, Case Western Reserve University, Cleveland, Ohio; and
| | - Gail Rosseau
- 1Gender Equity Initiative in Global Surgery, Boston, Massachusetts.,8Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| |
Collapse
|
31
|
Atesok K, Vaccaro A, Stippler M, Striano BM, Carr M, Heffernan M, Theiss S, Papavassiliou E. Fate of Hardware in Spinal Infections. Surg Infect (Larchmt) 2019; 21:404-410. [PMID: 31855116 DOI: 10.1089/sur.2019.206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Removal of hardware with irrigation and debridement in patients with surgical site infections (SSIs) is performed commonly. However, the removal of hardware from patients with SSIs after spinal procedures is controversial. Moreover, primary spinal infections such as spondylodiscitis may require instrumentation along with surgical debridement. The purpose of this article was to evaluate critically and summarize the available evidence related to retention of hardware in patients with deep SSIs, and the use of instrumentation in surgical treatment of primary spinal infections. Methods: A literature search utilizing PubMed database was performed. Studies reporting the management of deep SSIs after instrumented spinal procedures, and of primary spinal infections using instrumentation published in peer-reviewed journals were included. Identified publications were evaluated for relevance, and data were extracted from the studies deemed relevant. Results: Because SSIs occur typically during the early post-operative period before stable bony fusion has been achieved, the removal of instrumentation may be associated with instability of the spinal column, pseudarthrosis, progressive deformity, pain, loss of function, and deterioration in the activities of daily living (ADL). Hence, early SSIs after spinal instrumentation are usually treated without removal of hardware. Moreover, primary spinal infections such as spondylodiscitis may require surgical debridement and instrumentation in cases with associated instability. Conclusions: Retaining or using instrumentation in patients with SSIs after spinal procedures or in patients with primary spinal infections, respectively, are commonly practiced in the field of spine surgery. Further evidence is required for the development of definitive algorithms to guide spine surgeons in decision making regarding the fate of instrumentation in the treatment of spinal infections.
Collapse
Affiliation(s)
- Kivanc Atesok
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alexander Vaccaro
- Department of Orthopedic Surgery, Thomas Jefferson University, The Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Martina Stippler
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Brendan M Striano
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael Carr
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael Heffernan
- Department of Orthopaedic Surgery, Childrens Hospital of New Orleans, LSU Health Science Center, New Orleans, Louisiana, USA
| | - Steven Theiss
- Department of Orthopedic Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Efstathios Papavassiliou
- Department of Neurosurgery, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
32
|
Motiei-Langroudi R, Stippler M, Shi S, Adeeb N, Gupta R, Griessenauer CJ, Papavassiliou E, Kasper EM, Arle J, Alterman RL, Ogilvy CS, Thomas AJ. Factors predicting reoperation of chronic subdural hematoma following primary surgical evacuation. J Neurosurg 2019; 129:1143-1150. [PMID: 29243977 DOI: 10.3171/2017.6.jns17130] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 06/05/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEChronic subdural hematoma (CSDH) is commonly encountered in neurosurgical practice. However, surgical evacuation remains complicated by a high rate of reoperation. The optimal surgical approach to reduce the reoperation rate has not been determined. In the current study, the authors evaluated the prognostic value of clinical and radiographic factors to predict reoperation in the context of CSDH.METHODSA retrospective review of 325 CSDH patients admitted to an academic medical center in the United States, between 2006 and 2016, was performed. Clinical and radiographic factors predictive of the need for CSDH reoperation were identified on univariable and multivariable analyses.RESULTSUnivariable analysis showed that warfarin use, clopidogrel use, mixed hypo- and isointensity on T1-weighted MRI, greater preoperative midline shift, larger hematoma/fluid residual on first postoperative day CT, lesser decrease in hematoma size after surgery, use of monitored anesthesia care (MAC), and lack of intraoperative irrigation correlated with a significantly higher rate of reoperation. Multivariable analysis, however, showed that only the presence of loculation, clopidogrel or warfarin use, and percent of hematoma change after surgery significantly predicted the need for reoperation. Our results showed that 0% (no reduction), 50%, and 100% hematoma maximum thickness change (complete resolution of hematoma after surgery) were associated with a 41%, 6%, and < 1% rate of reoperation, respectively. The use of drains, either large diameter or small caliber, did not have any effect on the likelihood of reoperation.CONCLUSIONSAmong many factors, clopidogrel or warfarin use, hematoma loculation on preoperative CT, and the amount of hematoma evacuation on the first postoperative CT were the strongest predictors of reoperation.
Collapse
|
33
|
|
34
|
Nelton E, Maragkos G, Richter S, Filippidis A, Stippler M. Clinical Course of Intracranial Bleeding in Patients Anticoagulated With Factor Xa inhibitors Without the Use of Specific Reversal Agents. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_835] [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: 11/14/2022] Open
|
35
|
Maragkos G, Papavassiliou E, Stippler M, Filippidis A. Meta-Analysis of Functional Outcomes in 5508 Patients Sustaining a Gunshot Wound to the Head. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
36
|
Ravindran K, Stippler M. Book Review: Neurosurgery Rounds: Questions and Answers, Second Edition. Neurosurgery 2019. [DOI: 10.1093/neuros/nyy472] [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: 11/12/2022] Open
|
37
|
Maragkos GA, Papavassiliou E, Stippler M, Filippidis AS. Civilian Gunshot Wounds to the Head: Prognostic Factors Affecting Mortality: Meta-Analysis of 1774 Patients. J Neurotrauma 2018; 35:2605-2614. [DOI: 10.1089/neu.2018.5682] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Georgios A. Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Efstathios Papavassiliou
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aristotelis S. Filippidis
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, Boston Medical Center, Boston, Massachusetts
| |
Collapse
|
38
|
Motiei-Langroudi R, Thomas AJ, Ascanio L, Alturki A, Papavassiliou E, Kasper EM, Arle J, Alterman RL, Ogilvy CS, Stippler M. Factors Predicting the Need for Surgery of the Opposite Side After Unilateral Evacuation of Bilateral Chronic Subdural Hematomas. Neurosurgery 2018; 85:648-655. [DOI: 10.1093/neuros/nyy432] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 08/17/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Patients with bilateral chronic subdural hematoma (bCSDH) undergo unilateral evacuation for the large or symptomatic side because the contralateral hematoma is either small or asymptomatic. However, the contralateral hematoma may subsequently grow and require evacuation.
OBJECTIVE
To characterize factors that predict contralateral hematoma growth and need for evacuation.
METHODS
A retrospective study on 128 surgically treated bCSDHs.
RESULTS
Fifty-one and 77 were bilaterally and unilaterally evacuated, respectively. Glasgow Coma Scale was lower and midline shift was higher in those evacuated unilaterally compared to those evacuated bilaterally. Hematoma size was a significant determinant of decision for unilateral vs bilateral evacuation. The contralateral side needed evacuation at a later stage in 7 cases (9.1%). There was no significant difference in terms of reoperation rate between those evacuated unilaterally and bilaterally. Greater contralateral hematoma thickness on the first postoperative day computed tomography (CT) and more postoperative midline shift reversal had higher rates of operation in the opposite side. There was no difference between the daily pace of hematoma decrease in the operated and nonoperated sides (0.7% decrease per day vs 0.9% for the operated and nonoperated sides, respectively).
CONCLUSION
Results of this study show that most bCSDHs evacuated unilaterally do not experience growth in the nonoperated side and unilateral evacuation results in hematoma resolution for both sides in most cases. Hematoma thickness on the opposite side on the first postoperative day CT and amount of midline shift reversal after surgery are the most important factors predicting the need for surgery on the opposite side.
Collapse
Affiliation(s)
- Rouzbeh Motiei-Langroudi
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurological Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ajith J Thomas
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Luis Ascanio
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Abdulrahman Alturki
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Department of Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Efstathios Papavassiliou
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ekkehard M Kasper
- Division of Neurosurgery, Hamilton General Hospital, McMaster University, Hamilton ON, Canada
| | - Jeffrey Arle
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Ronnie L Alterman
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Martina Stippler
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
39
|
Stippler M, Liu J, Motiei-Langroudi R, Voronovich Z, Yonas H, Davis RB. Complicated Mild Traumatic Brain Injury and the Need for Imaging Surveillance. World Neurosurg 2017; 105:265-269. [PMID: 28502689 DOI: 10.1016/j.wneu.2017.05.008] [Citation(s) in RCA: 7] [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: 02/02/2017] [Revised: 04/29/2017] [Accepted: 05/02/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the need for repeat head computed tomography (CT) in patients with complicated mild traumatic brain injury (TBI) determined nonoperative after the first head CT. METHODS A total of 380 patients with mild TBI and a positive head CT not needing surgery were included. Changes between first and second head CT were categorized as decreased, increased, or stable. RESULTS Three patients required neurosurgical intervention (0.8%) after the second CT. There were no significant differences in demographics including age, gender, alcohol consumption, anticoagulation status, time between first and second CT, Glasgow Coma Scale score at admission and discharge, and incidence of subarachnoid hemorrhage, epidural hematoma, contusion, or skull fractures between the operated and nonoperated groups. All patients in the operated group had subdural hematoma compared with 40.8% in the nonoperated group (P = 0.07). All operated patients showed symptoms of neurologic worsening after initial head CT, compared with 2.7% in the nonoperated group (P < 0.001). Moreover, patients who showed neurologic worsening were more likely to show increased intracranial bleeding on repeat head CT, whereas patients who did not show neurologic worsening were more likely to show decreased or stable intracranial bleeding (P = 0.04). CONCLUSIONS Routine repeat head CT in patients with complicated mild TBI is very low yield to predict need for delayed surgical intervention. Instead, serial neurologic examination and observation over the first 8 hours after the injury is recommended. A second CT scan should be obtained only in patients who have neurologic worsening.
Collapse
Affiliation(s)
- Martina Stippler
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
| | - Jingyi Liu
- School of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Rouzbeh Motiei-Langroudi
- Neurosurgery Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Zoya Voronovich
- Department of Neurosurgery, University of New Mexico Health Science Center, Albuquerque, New Mexico, USA
| | - Howard Yonas
- Department of Neurosurgery, University of New Mexico Health Science Center, Albuquerque, New Mexico, USA
| | - Roger B Davis
- Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
40
|
Abstract
IgG4-related hypophysitis is a rare, inflammatory process of the pituitary that mimics more commonly seen pituitary tumors. We report a case of IgG4-related hypophysitis in a 16-year-old female with diabetes insipidus who was found to have IgG4-related hypophysitis based on tissue diagnosis. This entity has not been previously described in a pediatric patient. Recognition of certain inflammatory processes of the pituitary may lead to alternative means of diagnosis and medical management without a biopsy.
Collapse
Affiliation(s)
- Lauren Decker
- Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | - Gamaliel Lorenzo
- Department of Radiology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | | | | | - Karen SantaCruz
- Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| |
Collapse
|
41
|
Proskynitopoulos PJ, Stippler M, Kasper EM. Post-traumatic anosmia in patients with mild traumatic brain injury (mTBI): A systematic and illustrated review. Surg Neurol Int 2016; 7:S263-75. [PMID: 27213113 PMCID: PMC4866055 DOI: 10.4103/2152-7806.181981] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 01/27/2016] [Accepted: 04/01/2016] [Indexed: 11/23/2022] Open
Abstract
Background: Olfactory dysfunction (OD) is a disorder associated with traumatic brain injury (TBI), which is prevalent in up to 20% of patients suffering from TBI. Nevertheless, most studies focusing on the relationship between OD and TBIs do not differentiate between the different types of TBI (mild, medium, and severe). In this paper, we conducted a comprehensive and systematic review of the existing literature for the association between mild TBI (mTBI) and OD in order to examine their relationship, focusing on its neurosurgical management and the radiographic characteristics. Methods: The MEDLINE database was systematically reviewed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. We found 66 articles, of which 10 fulfilled our criteria. Results: All except two studies reported a significant association between trauma severity and olfaction. Two studies found a negative correlation between TBI severity and olfactory bulb volume with one reporting an r value of −0.62). Three studies reported an association between the observation of radiographic intracranial hemorrhage or skull base fractures and the history of TBI. Conclusion: According to our search results, we conclude that OD is a prevalent but underdiagnosed problem in mTBI. Because OD is associated with a significant decrease in quality of life, we think that neurosurgical teams need to asses olfactory function in mTBI patients when they report to clinics. To illustrate this scenario, we include two distinct cases of patients with anosmia after mTBI in this review. Finally, we suggest a treatment algorithm for patients with mTBI so that a possible OD can be diagnosed and treated as early as possible.
Collapse
Affiliation(s)
| | - Martina Stippler
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, USA
| | - Ekkehard M Kasper
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, USA
| |
Collapse
|
42
|
Affiliation(s)
- Martina Stippler
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | - Pedro Ramirez
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | - Aldo Berti
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | - Chamisa MacIndoe
- Department of NeurosurgeryUniversity of New Mexico, Albuquerque, NM, USA
| | | | | |
Collapse
|
43
|
Mayer AR, Yang Z, Yeo RA, Pena A, Ling JM, Mannell MV, Stippler M, Mojtahed K. A functional MRI study of multimodal selective attention following mild traumatic brain injury. Brain Imaging Behav 2012; 6:343-54. [PMID: 22673802 DOI: 10.1007/s11682-012-9178-z] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Previous work suggests that the ability to selectively attend to and resolve conflicting information may be the most enduring cognitive deficit following mild traumatic brain injury (mTBI). The current study used fMRI to evaluate potential differences in hemodynamic activation in 22 mTBI patients and 22 carefully matched healthy controls (HC) during a multimodal selective attention task (numeric Stroop). Behavioral data indicated faster reaction times for congruent versus incongruent trials and for stimuli presented at 0.66 compared to 0.33 Hz across both groups, with minimal differences in behavioral performance across the groups. Similarly, there were no group-wise differences in functional activation within lateral and medial prefrontal cortex during the execution of cognitive control (incongruent versus congruent trials). In contrast, within-group comparisons indicated robust patterns of attention-related modulations (ARM) within the bilateral dorsolateral prefrontal cortex and bilateral visual streams for HC but not mTBI patients. In addition, mTBI patients failed to exhibit task-induced deactivation within the default-mode network (DMN) under conditions of higher attentional load. In summary, in spite of near normal behavioral performance, current results suggest within-group abnormalities during both the top-down allocation of visual attention and in regulating the DMN during the semi-acute stage of mTBI.
Collapse
Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, NM 87106, USA.
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Carlson AP, Stippler M, Myers O. Predictive factors for vision recovery after optic nerve decompression for chronic compressive neuropathy: systematic review and meta-analysis. J Neurol Surg B Skull Base 2012; 74:20-38. [PMID: 24436885 DOI: 10.1055/s-0032-1329624] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 06/08/2012] [Indexed: 10/27/2022] Open
Abstract
Objectives Surgical optic nerve decompression for chronic compressive neuropathy results in variable success of vision improvement. We sought to determine the effects of various factors using meta-analysis of available literature. Design Systematic review of MEDLINE databases for the period 1990 to 2010. Setting Academic research center. Participants Studies reporting patients with vision loss from chronic compressive neuropathy undergoing surgery. Main outcome measures Vision outcome reported by each study. Odds ratios (ORs) and 95% confidence intervals (CIs) for predictor variables were calculated. Overall odds ratios were then calculated for each factor, adjusting for inter study heterogeneity. Results Seventy-six studies were identified. Factors with a significant odds of improvement were: less severe vision loss (OR 2.31[95% CI = 1.76 to 3.04]), no disc atrophy (OR 2.60 [95% CI = 1.17 to 5.81]), smaller size (OR 1.82 [95% CI = 1.22 to 2.73]), primary tumor resection (not recurrent) (OR 3.08 [95% CI = 1.84 to 5.14]), no cavernous sinus extension (OR 1.88 [95% CI = 1.03 to 3.43]), soft consistency (OR 4.91 [95% CI = 2.27 to 10.63]), presence of arachnoid plane (OR 5.60 [95% CI = 2.08 to 15.07]), and more extensive resection (OR 0.61 [95% CI = 0.4 to 0.93]). Conclusions Ophthalmologic factors and factors directly related to the lesion are most important in determining vision outcome. The decision to perform optic nerve decompression for vision loss should be made based on careful examination of the patient and realistic discussion regarding the probability of improvement.
Collapse
Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, United States
| | - Martina Stippler
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, United States
| | - Orrin Myers
- Department of Internal Medicine, University of New Mexico, Albuquerque, New Mexico, United States
| |
Collapse
|
45
|
Stippler M, Ortiz V, Adelson PD, Chang YF, Tyler-Kabara EC, Wisniewski SR, Fink EL, Kochanek PM, Brown SD, Bell MJ. Brain tissue oxygen monitoring after severe traumatic brain injury in children: relationship to outcome and association with other clinical parameters. J Neurosurg Pediatr 2012; 10:383-91. [PMID: 22978637 DOI: 10.3171/2012.8.peds12165] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT Minimizing secondary brain injuries after traumatic brain injury (TBI) in children is critical to maximizing neurological outcome. Brain tissue oxygenation monitoring (as measured by interstitial partial pressure of O2 [PbO2]) is a new tool that may aid in guiding therapies, yet experience in children is limited. This study aims to describe the authors' experience of PbO2 monitoring after TBI. It was hypothesized that PbO2 thresholds could be established that were associated with favorable neurological outcome, and it was determined whether any relationships between PbO2 and other important clinical variables existed. METHODS Forty-six children with severe TBI (Glasgow coma scale score ≤ 8 after resuscitation) who underwent PbO2 and brain temperature monitoring between September 2004 and June 2008 were studied. All patients received standard neurocritical care, and 24 were concurrently enrolled in a trial of therapeutic early hypothermia (n = 12/group). The PbO2 was measured in the uninjured frontal cortex. Hourly recordings and calculated daily means of various variables including PbO2, intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial blood pressure, partial pressure of arterial O2, and fraction of inspired O2 were compared using several statistical approaches. Glasgow outcome scale scores were determined at 6 months after injury. RESULTS The mean patient age was 9.4 years (range 0.1-16.5 years; 13 girls) and 8554 hours of monitoring were analyzed (PbO2 range 0.0-97.2 mm Hg). A PbO2 of 30 mm Hg was associated with the highest sensitivity/specificity for favorable neurological outcome at 6 months after TBI, yet CPP was the only factor that was independently associated with favorable outcome. Surprisingly, instances of preserved PbO2 with altered ICP and CPP were observed in some children with unfavorable outcomes. CONCLUSIONS Monitoring of PbO2 demonstrated complex interactions with clinical variables reflecting intracranial dynamics using this protocol. A higher threshold than reported in studies in adults was suggested as a potential therapeutic target, but this threshold was not associated with improved outcomes. Additional studies to assess the utility of PbO2 monitoring after TBI in children are needed.
Collapse
Affiliation(s)
- Martina Stippler
- Department of Neurological Surgery, Safar Center for Resuscitation Research, University of Pittsburgh, Pennsylvania 15260, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Stippler M, Yonas H, Karlovitz A. 118 Feasibility and Utilization of Teleradiology in Neurosurgery. Neurosurgery 2012. [DOI: 10.1227/01.neu.0000417708.34918.7a] [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
|
47
|
Kaloostian P, Robertson C, Gopinath SP, Stippler M, King CC, Qualls C, Yonas H, Nemoto EM. Outcome prediction within twelve hours after severe traumatic brain injury by quantitative cerebral blood flow. J Neurotrauma 2012; 29:727-34. [PMID: 22111910 DOI: 10.1089/neu.2011.2147] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We measured quantitative cortical mantle cerebral blood flow (CBF) by stable xenon computed tomography (CT) within the first 12 h after severe traumatic brain injury (TBI) to determine whether neurologic outcome can be predicted by CBF stratification early after injury. Stable xenon CT was used for quantitative measurement of CBF (mL/100 g/min) in 22 cortical mantle regions stratified as follows: low (0-8), intermediate (9-30), normal (31-70), and hyperemic (>70) in 120 patients suffering severe (Glasgow Coma Scale [GCS] score ≤8) TBI. For each of these CBF strata, percentages of total cortical mantle volume were calculated. Outcomes were assessed by Glasgow Outcome Scale (GOS) score at discharge (DC), and 1, 3, and 6 months after discharge. Quantitative cortical mantle CBF differentiated GOS 1 and GOS 2 (dead or vegetative state) from GOS 3-5 (severely disabled to good recovery; p<0.001). Receiver operating characteristic (ROC) curve analysis for percent total normal plus hyperemic flow volume (TNHV) predicting GOS 3-5 outcome at 6 months for CBF measured <6 and <12 h after injury showed ROC area under the curve (AUC) cut-scores of 0.92 and 0.77, respectively. In multivariate analysis, percent TNHV is an independent predictor of GOS 3-5, with an odds ratio of 1.460 per 10 percentage point increase, as is initial GCS score (OR=1.090). The binary version of the Marshall CT score was an independent predictor of 6-month outcome, whereas age was not. These results suggest that quantitative cerebral cortical CBF measured within the first 6 and 12 h after TBI predicts 6-month outcome, which may be useful in guiding patient care and identifying patients for randomized clinical trials. A larger multicenter randomized clinical trial is indicated.
Collapse
Affiliation(s)
- Paul Kaloostian
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Stippler M, Smith C, McLean AR, Carlson A, Morley S, Murray-Krezan C, Kraynik J, Kennedy G. Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature. Emerg Med J 2012; 29:528-32. [PMID: 22307924 DOI: 10.1136/emermed-2011-200162] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the efficacy of routine follow-up CT scans of the head after complicated mild traumatic brain injury (TBI). METHODS 74 English language studies published from 1999 to February 2011 were reviewed. The papers were found by searching the PubMed database using a combination of keywords according to Cochrane guidelines. Excluding studies with missing or inappropriate data, 1630 patients in 19 studies met the inclusion criteria: complicated mild TBI, defined as a GCS score 13-15 with abnormal initial CT findings and the presence of follow-up CT scans. For these studies, the progression and type of intracranial haemorrhage, time from trauma to first scan, time between first and second scans, whether second scans were obtained routinely or for neurological decline and the number of patients who had a neurosurgical intervention were recorded. RESULTS Routine follow-up CT scans showed hemorrhagic progression in 324 patients (19.9%). Routine follow-up head CT scans did not predict the need for neurosurgical intervention (p=0.10) but a CT scan of the head performed for decline in status did (p=0.00046). For the 56 patients (3.4%) who declined neurologically, findings on the second CT scan were worse in 38 subjects (67%) and unchanged in the rest. Overall, 39 patients (2.4%) underwent neurosurgical intervention. CONCLUSION Routine follow-up CT scans rarely alter treatment for patients with complicated mild TBI. Follow-up CT scans based on neurological decline alter treatment five times more often than routine follow-up CT scans.
Collapse
Affiliation(s)
- Martina Stippler
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131-0001, USA.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Carlson A, Stippler M, Morley S, Myers O. Predictive Factors for Vision Recovery after Optic Nerve Decompression for Chronic Compressive Neuropathy: Systematic Review and Meta-Analysis. Skull Base 2011. [DOI: 10.1055/s-2011-1274186] [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: 10/18/2022]
|
50
|
Carlson AP, Ramirez P, Kennedy G, McLean AR, Murray-Krezan C, Stippler M. Low rate of delayed deterioration requiring surgical treatment in patients transferred to a tertiary care center for mild traumatic brain injury. Neurosurg Focus 2010; 29:E3. [PMID: 21039137 DOI: 10.3171/2010.8.focus10182] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [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
OBJECT Patients with mild traumatic brain injury (mTBI) only rarely need neurosurgical intervention; however, there is a subset of patients whose condition will deteriorate. Given the high resource utilization required for interhospital transfer and the relative infrequency of the need for intervention, this study was undertaken to determine how often patients who were transferred required intervention and if there were factors that could predict that need. METHODS The authors performed a retrospective review of cases involving patients who were transferred to the University of New Mexico Level 1 trauma center for evaluation of mTBI between January 2005 and December 2009. Information including demographic data, lesion type, need for neurosurgical intervention, and short-term outcome was recorded. RESULTS During the 4-year study period, 292 patients (age range newborn to 92 years) were transferred for evaluation of mTBI. Of these 292 patients, 182 (62.3%) had an acute traumatic finding of some kind; 110 (60.4%) of these had a follow-up CT to evaluate progression, whereas 60 (33.0%) did not require a follow-up CT. In 15 cases (5.1% overall), the patients were taken immediately to the operating room (either before or after the first CT). Only 4 patients (1.5% overall) had either clinical or radiographic deterioration requiring delayed surgical intervention after the second CT scan. Epidural hematoma (EDH) and subdural hematoma (SDH) were both found to be significantly associated with the need for surgery (OR 29.5 for EDH, 95% CI 6.6-131.8; OR 9.7 for SDH, 95% CI 2.4-39.1). There were no in-hospital deaths in the series, and 97% of patients were discharged with a Glasgow Coma Scale score of 15. CONCLUSIONS Most patients who are transferred with mTBI who need neurosurgical intervention have a surgical lesion initially. Only a very small percentage will have a delayed deterioration requiring surgery, with EDH and SDH being more concerning lesions. In most cases of mTBI, triage can be performed by a neurosurgeon and the patient can be observed without interhospital transfer.
Collapse
Affiliation(s)
- Andrew P Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico 87131, USA
| | | | | | | | | | | |
Collapse
|