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Hines K, Philipp L, Thalheimer S, Montenegro TS, Gonzalez GA, Hughes LP, Leibold A, Mahtabfar A, Franco D, Heller JE, Jallo J, Prasad S, Sharan AD, Harrop JS. Increased Surgeon-specific Experience and Volume is Correlated With Improved Clinical Outcomes in Lumbar Fusion Patients. Clin Spine Surg 2023; 36:E86-E93. [PMID: 36006405 DOI: 10.1097/bsd.0000000000001377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population. OBJECTIVE This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics. SUMMARY OF BACKGROUND DATA Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited. METHODS This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI. RESULTS A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression ( P =0.0340 and P =0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID. CONCLUSION This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.
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Affiliation(s)
- Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA
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Gonzalez GA, Porto G, Hines K, Franco D, Montenegro TS, Mahtabfar A, O’Leary M, Miao J, Thalheimer S, Heller JE, Sharan A, Harrop J. Clinical Outcomes with and without Adherence to Evidence-Based Medicine Guidelines for Lumbar Degenerative Spondylolisthesis Fusion Patients. J Clin Med 2023; 12:jcm12031200. [PMID: 36769851 PMCID: PMC9917667 DOI: 10.3390/jcm12031200] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Degenerative lumbar spondylolisthesis (DS) patients are treated with instrumented fusion, following EBM guidelines, and typically have excellent clinical outcomes. However, not all lumbar fusion procedures adhere to EBM guidelines, typically due to a lack of prospective data. OBJECTIVE This retrospective study compared outcomes of DS lumbar fusion patients treated according to EBM guidelines (EBM concordant) to lumbar fused patients with procedures that did not have clear EBM literature that supported this treatment, the goal being to examine the value of present EBM to guide clinical care. METHODS A total of 125 DS patients were considered EBM concordant, while 21 patients were EBM discordant. Pre- and postsurgical ODI scores were collected. Clinical outcomes were stratified into substantial clinical benefit (SCB ΔODI >10 points), minimal clinical importance benefit (MCID ΔODI ≥ 5 points), no MCID (ΔODI < 5 points), and a group that showed no change or worsening ODI. Fisher's exact and χ2 tests for categorical variables, Student's t-test for continuous variables, and descriptive statistics were used. Statistical tests were computed at the 95% level of confidence. RESULTS Analysis of 125 degenerative spondylolisthesis patients was performed comparing preoperative and postoperative (6 months) ODI scores. ODI improved by 8 points in the EBM concordant group vs. 2.1 points in the EBM discordant group (p = 0.002). Compliance with EBM guidelines was associated with an odds ratio (OR) of 2.93 for achieving MCID ([CI]: 1.12-7.58, p = 0.027). CONCLUSIONS Patients whose lumbar fusions met EBM criteria had better self-reported outcomes at six months than those who did not meet the requirements. A greater knowledge set is needed to help further support EBM-guided patient care.
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Affiliation(s)
- Glenn A. Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
- Correspondence:
| | - Guilherme Porto
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Daniel Franco
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Thiago S. Montenegro
- Department of Neurosurgery, Spectrum Health/Michigan State University, Grand Rapids, MI 49503, USA
| | - Aria Mahtabfar
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Matthew O’Leary
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA 19104, USA
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Sara Thalheimer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Joshua E. Heller
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA 19107, USA
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Gonzalez GA, Corso K, Kr S, Porto G, Wainwright J, Franco D, Miao J, Hines K, O'Leary M, Mouchtouris N, Mahtabfar A, Neavling N, Montenegro TS, Thalheimer S, Sharan A, Jallo J, Harrop J. Incidence of Pseudarthrosis and Subsequent Surgery After Cervical Fusion Surgery: A Retrospective Review of a National Health Care Claims Database. World Neurosurg 2022; 167:e806-e845. [PMID: 36041719 DOI: 10.1016/j.wneu.2022.08.094] [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: 07/28/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cervical pseudarthrosis is a postoperative adverse event that occurs when a surgically induced fusion fails to establish bone growth connecting the 2 regions. It has both clinical and financial implications and may result in significant patient morbidity; it continues to be one of the leading causes of pain after surgery. METHODS A retrospective longitudinal cohort study was performed. Patients in the IBM MarketScan Commercial Claims and Encounters (CCAE) database, 18-64 years old, who underwent elective cervical fusions during 2015-2019 were included. Patients with trauma, infection, or neoplasm were excluded. Patients were followed for 2 years from surgical fusion for occurrence of pseudarthrosis. After pseudarthrosis, subsequent surgery was documented, and cumulative incidence curves, adjusted for patient/procedure characteristics, with 95% confidence intervals (CIs) were generated. Risk factors were evaluated with multivariable Cox regression analysis. RESULTS The cohort included 45,584 patients. The 1-year and 2-year incidence of pseudarthrosis was 2.0% (95% CI, 1.9%-2.2%) and 3.3% (95% CI, 3.1%-3.5%), respectively. Factors significantly associated with increased risk of pseudarthrosis were female gender, current/previous substance abuse, previous spinal pain in the cervical/thoracic/lumbar spine, and Elixhauser score ≥5. Factors significantly associated with decreased risk of pseudarthrosis were anterior cervical approach, use of an interbody cage, and 2-level or 3-level anterior instrumentation. The 1-year and 2-year incidence of subsequent surgery in patients with pseudarthrosis was 11.7% (95% CI, 9.6%-13.7%) and 13.8% (95% CI, 11.5%-16.2%), respectively. CONCLUSIONS Cervical pseudarthrosis and subsequent surgery still occur at a low rate. Surgical factors such as anterior approach, interbody cage use, and anterior instrumentation may reduce pseudarthrosis risk.
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Affiliation(s)
- Glenn A Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
| | - Katherine Corso
- Real World Data Sciences, Medical Device Epidemiology, Johnson & Johnson, New Brunswick, New Jersey, USA
| | | | - Guilherme Porto
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - John Wainwright
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Daniel Franco
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Matthew O'Leary
- Department of Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Aria Mahtabfar
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Nathaniel Neavling
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Thiago S Montenegro
- Department of Neurosurgery, Spectrum Health/Michigan State University, Grand Rapids, Michigan, USA
| | - Sara Thalheimer
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Gonzalez GA, Franco D, Porto G, Elia C, Hattar E, Hines K, Mahtabfar A, O'Leary M, Philipp L, Atallah E, Montenegro TS, Heller J, Sharan A, Jallo J, Harrop J. Does the Number of Levels of Decompression Have an Impact on the Clinical Outcomes of Patients With Lumbar Degenerative Spondylolisthesis: A Retrospective Study in Single-Level Fused Patients. Cureus 2022; 14:e27804. [PMID: 36134108 PMCID: PMC9481219 DOI: 10.7759/cureus.27804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 11/05/2022] Open
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Hines K, Elmer N, Detweiler M, Fatema U, Gonzalez GA, Montenegro TS, Franco D, Prasad S, Jallo J, Sharan A, Heller J, Boon M, Spiegel J, Harrop J. Combined Anterior Osteophytectomy and Cricopharyngeal Myotomy for Treatment of DISH-Associated Dysphagia. Global Spine J 2022; 12:877-882. [PMID: 33203249 PMCID: PMC9344495 DOI: 10.1177/2192568220967358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective observational case series. OBJECTIVE To assess the outcome of patients with diffuse idiopathic skeletal hyperostosis (DISH) with dysphagia who underwent cricopharyngeal myotomy (CPM) in conjunction with anterior osteophytectomy (OP). METHODS This is a retrospective observational study of 9 patients that received combined intervention by neurosurgeons and otolaryngologists. Inclusion criteria for surgery consisted of patients who failed to respond to conservative treatments for dysphagia and had evidence of both upper esophageal dysfunction and osteophyte compression. We present the largest series in literature to date including patients undergoing combined OP and CPM. RESULTS A total of 88.9% (8/9) of the patients who underwent OP and CPM showed improvement in their symptoms. Of the aforementioned group, 22.2% of these patients had complete resolution of their symptoms, 11.1% did not improve, and only 2 patients showed recurrence of their symptoms. None of the patients in whom surgery was performed required reoperation or suffered serious complication related to the surgical procedures. CONCLUSION Based on the literature results, high rate of improvements in dysphagia, and low rate of complications, combined OP and CPM procedures may be beneficial to a carefully selected group of patients.
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Affiliation(s)
- Kevin Hines
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Nicholas Elmer
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Maxwell Detweiler
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Umma Fatema
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Glenn A. Gonzalez
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Thiago S. Montenegro
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Daniel Franco
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Srinivas Prasad
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Jack Jallo
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Ashwini Sharan
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Joshua Heller
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA
| | - Maurits Boon
- Thomas Jefferson University,
Philadelphia, PA, USA
| | | | - James Harrop
- Thomas Jefferson University,
Philadelphia, PA, USA,Jefferson Hospital for Neuroscience,
Philadelphia, PA, USA,James Harrop, Division of Spine and
Peripheral Nerve Surgery, Department of Neurological Surgery, Thomas Jefferson
University Hospital, 901 Walnut Street 3rd Floor, Philadelphia, PA 19107, USA.
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Matias CM, Velagapudi L, Montenegro TS, Heller JE. Minimally Invasive Sacroiliac Fusion-a Review. Curr Pain Headache Rep 2022; 26:173-182. [PMID: 35138566 DOI: 10.1007/s11916-022-01016-y] [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] [Accepted: 12/30/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW Sacroiliac dysfunction is an important cause of low back pain with significant impact on quality of life and daily activities. Minimally invasive sacroiliac joint fusion (MIS SI fusion) is an effective treatment for patients who failed non-surgical strategies. The purpose of this article is to review the clinical outcomes and complications of this surgical technique. RECENT FINDINGS For patients with SI joint dysfunction, MIS SI fusion reduced pain and disability as measured by Visual Analog Scale and Oswestry Index and improved quality of life as measured by Short-Form 36 and EuroQol-5D questionnaires. Satisfaction rates were higher in the SI fusion group when compared to the conservative management. In recent clinical trials, adverse events occurred with a similar rate in the first 6 months for patients assigned in the conservative management versus patients assigned to MIS SI fusion. MIS SI fusion is an effective and safe procedure for patients with sacroiliac dysfunction who failed non-surgical strategies. This procedure provides rapid as well as sustained pain relief, improvement in back function, high patient satisfaction, with low rate of complications.
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Affiliation(s)
- Caio M Matias
- Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA.
| | - Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
| | - Thiago S Montenegro
- Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
| | - Joshua E Heller
- Department of Neurosurgery, Thomas Jefferson University, 909 Walnut Street, 3rd Floor, Philadelphia, PA, 19107, USA
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Rodrigues-Pinto R, Montenegro TS, Davies BM, Kato S, Kawaguchi Y, Ito M, Zileli M, Kwon BK, Fehlings MG, Koljonen PA, Kurpad SN, Guest JD, Aarabi B, Rahimi-Movaghar V, Wilson JR, Kotter MRN, Harrop JS. Optimizing the Application of Surgery for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 10]. Global Spine J 2022; 12:147S-158S. [PMID: 35174733 PMCID: PMC8859702 DOI: 10.1177/21925682211062494] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To introduce the number 10 research priority for Degenerative Cervical Myelopathy: Individualizing Surgery. METHODS This article summarizes the current recommendations and indications for surgery, including how known prognostic factors such as injury time, age, disease severity, and associated comorbidities impact surgical outcome. It also considers key areas of uncertainty that should be the focus of future research. RESULTS While a small proportion of conservatively managed patients may remain stable, the majority will deteriorate over time. To date, surgical decompression is the mainstay of treatment, able to halt disease progression and improve neurologic function and quality of life for most patients. Whilst this recognition has led to recommendations on when to offer surgery, there remain many uncertainties including the type of surgery, or timing in milder and/or asymptomatic cases. Their clarification has the potential to transform outcomes, by ensuring surgery offers each individual its maximum benefit. CONCLUSION Developing the evidence to better guide surgical decision-making at the individual patient level is a research priority for Degenerative Cervical Myelopathy.
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Affiliation(s)
- Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Thiago S. Montenegro
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | | | - Manabu Ito
- Department of Orthopaedic Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Mehmet Zileli
- Neurosurgery Department, Ege University, Bornova, Izmir, Turkey
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, ON, Canada
| | - Paul A. Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Iran
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, ON, Canada
| | | | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
Low back pain is the leading cause of disability worldwide in industrialized nations. The pathology underlying chronic low back pain is associated with numerous factors. Lumbar degenerative disc disease is a potential major source of low back pain. There are numerous treatment modalities and options. Nonsurgical treatment options exist in the form of pain management through a combination of anti-inflammatory medications and steroid injections, physical therapy and lifestyle modifications. This article reviews the history and current trends in use for lumbar toral disc arthroplasty for degenerative disc disease treatment. Furthermore, indications, contraindications, and complications management are discussed.
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Affiliation(s)
- Daniel Franco
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Room 320L, Philadelphia, PA 19107, USA.
| | - Garrett Largoza
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Room 320L, Philadelphia, PA 19107, USA
| | - Thiago S Montenegro
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Room 320L, Philadelphia, PA 19107, USA
| | - Glenn A Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Room 320L, Philadelphia, PA 19107, USA
| | - Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Room 320L, Philadelphia, PA 19107, USA
| | - James Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospitals, 909 Walnut Street, Room 320L, Philadelphia, PA 19107, USA
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9
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Montenegro TS, Gonzalez GA, Saiegh FA, Philipp L, Hines K, Hattar E, Franco D, Mahtabfar A, Keppetipola KM, Leibold A, Atallah E, Fatema U, Thalheimer S, Wu C, Prasad SK, Jallo J, Heller J, Sharan A, Harrop J. Clinical outcomes in revision lumbar spine fusions: an observational cohort study. J Neurosurg Spine 2021; 35:437-445. [PMID: 34359034 DOI: 10.3171/2020.12.spine201908] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors compared primary lumbar spine fusions with revision fusions by using patient Oswestry Disability Index (ODI) scores to evaluate the impact of the North American Spine Society (NASS) evidence-based medicine (EBM) lumbar fusion indications on patient-reported outcome measures of revision surgeries. METHODS This study was a retrospective analysis of a prospective observational cohort of patients who underwent elective lumbar fusion between January 2018 and December 2019 at a single quaternary spine surgery service and had a minimum of 6 months of follow-up. A prospective quality improvement database was constructed that included the data from all elective lumbar spine surgeries, which were categorized prospectively as primary or revision surgeries and EBM-concordant or EBM-discordant revision surgeries based on the NASS coverage EBM policy. In total, 309 patients who met the inclusion criteria were included in the study. The ODIs of all groups (primary, revision, revision EBM concordant, and revision EBM discordant) were statistically compared. Differences in frequencies between cohorts were evaluated using chi-square and Fisher's exact tests. The unpaired 2-tailed Student t-test and the Mann-Whitney U-test for nonparametric data were used to compare continuous variables. Logistic regression was performed to determine the associations between independent variables (surgery status and NASS criteria indications) and functional outcomes. RESULTS Primary lumbar fusions were significantly associated with improved functional outcomes compared with revisions, as evidenced by ODI scores (OR 1.85, 95% CI 1.16-2.95 to achieve a minimal clinically important difference, p = 0.01). The percentage of patients whose functional status had declined at the 6-month postoperative evaluation was significantly higher in patients who had undergone a revision surgery than in those who underwent a primary surgery (23% vs 12.3%, respectively). An increase in ODI score, indicating worse clinical outcome after surgery, was greater in patients who underwent revision procedures (OR 2.14, 95% CI 1.17-3.91, p = 0.0014). Patients who underwent EBM-concordant revision surgery had significantly improved mean ODI scores compared with those who underwent EBM-discordant revision surgery (7.02 ± 5.57 vs -4.6 ± 6.54, p < 0.01). CONCLUSIONS The results of this prospective quality improvement program investigation illustrate that outcomes of primary lumbar fusions were superior to outcomes of revisions. However, revision procedures that met EBM guidelines were associated with greater improvements in ODI scores, which indicates that the use of defined EBM guideline criteria for reoperation can improve clinical outcomes of revision lumbar fusions.
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Stricsek GP, Montenegro TS, Gonzalez GA, Singh A, Harrop C, Harrop J. Association Between Postoperative Fever and Readmission Rates in Lumbar Fusion Patients. Clin Spine Surg 2021; 34:E349-E353. [PMID: 33560013 DOI: 10.1097/bsd.0000000000001131] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 12/22/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This is a retrospective observational study. OBJECTIVE This study evaluates the impact of postoperative fever on the rate of readmission among lumbar fusion patients. SUMMARY OF BACKGROUND DATA Postoperative fever is a common event across surgical specialties that often triggers an extensive work-up that can significantly increase hospital costs and length of stay, although the results are usually negative for infection. There is a paucity of literature studying postoperative fever in lumbar fusion patients. MATERIALS AND METHODS A retrospective chart review of all the patients who underwent elective posterior lumbar spinal fusion from January, 2018 to November, 2018 was conducted. Fever was defined as a temperature >100.4ºF. Patients were categorized into 4 groups based on their highest recorded temperature postoperatively. The association between demographic variables, tests ordered per patient, length of stay, and readmission rates per group were analyzed using a t test, and 1-way analysis of variance for continuous outcomes, and the Fisher exact test for categorical variables. RESULTS Of 107 patients, 58% had no fever recorded, 17.75% had temperatures between 100.5 and 100.90ºF, 18.69% temperatures between 101 and 101.90ºF, and 4.67% of patients temperatures equal or higher than 102.0ºF. The number of tests per patient increase with the range of temperatures analyzed (P<0.01), but the rate of readmission of all the 4 groups are not significantly different (0.107). There is no significant difference in the number of febrile episodes per day between patients who were and who were not readmitted (0.209). CONCLUSIONS A diagnostic testing policy guided by clinician assessment of symptoms and physical exam may limit unnecessary testing and reduce hospital length of stay and cost without sacrificing patient safety.
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Affiliation(s)
- Geoffrey P Stricsek
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Thiago S Montenegro
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Glenn A Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Akash Singh
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
| | - Catriona Harrop
- Department of Medicine and Neurologic Surgery, Vickie and Jack Farber Institute for Neurosciences, Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience
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11
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Montenegro TS, Elia C, Hines K, Buser Z, Wilson J, Ghogawala Z, Kurpad SN, Sciubba DM, Harrop JS. Are Lumbar Fusion Guidelines Followed? A Survey of North American Spine Surgeons. Neurospine 2021; 18:389-396. [PMID: 34218620 PMCID: PMC8255757 DOI: 10.14245/ns.2142136.068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. METHODS An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. RESULTS A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). CONCLUSION This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.
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Affiliation(s)
- Thiago S. Montenegro
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Christopher Elia
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jefferson Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Shekar N. Kurpad
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Daniel M. Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James S. Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
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12
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Ghosh R, Velagapudi L, Montenegro TS, Hines K, Gonzalez GA, Mahtabfar A, Prasad S, Jallo J, Sharan A, Heller J, Harrop J. Operative versus Nonoperative Management of Idiopathic Spinal Cord Herniation: Effect on Symptomatology and Disease Progression. World Neurosurg 2021; 152:e149-e154. [PMID: 34033961 DOI: 10.1016/j.wneu.2021.05.046] [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: 03/27/2021] [Revised: 05/13/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Idiopathic spinal cord herniation (ISCH) is a rare pathology characterized by extravasation of the spinal cord through a dural defect. The optimal algorithm for choosing operative or nonoperative management is not well elucidated, partially because of the rarity of this pathology. We present the largest single-center series of ISCH and compare operative treatment to conservative management. METHODS A retrospective case series of all patients evaluated for treatment of ISCH at our institution between 2010 and 2019 was conducted. Demographic variables, presenting symptoms, and imaging characteristics were assessed for all patients. For patients who underwent operative treatment, surgical approach, postoperative course, and discharge outcomes were recorded. Follow-up notes were reviewed for status of symptoms and functional capabilities, which were synthesized into Odom's criteria score. RESULTS Sixteen patients met the inclusion criteria for this study, 8 of whom underwent operative treatment. No significant differences were found between operative and nonoperative groups with regard to demographic variables or pathology characteristics. Odom's criteria scores for the operative cohort were 12.5% (1 of 8) Excellent, 62.5% (5 of 8) Good, 12.5% (1 of 8) Fair, and 12.5% (1 of 8) Poor. Odom's criteria scores for the nonoperative cohort were 16.7% (1 of 6) Excellent, 33.3% (2 of 6) Good, 16.7% (1 of 6) Fair, and 33.3% (2 of 6) Poor. There was no significant difference between Odom's criteria score distribution between the operative and nonoperative groups at latest follow up (P = 0.715). CONCLUSIONS Conservative management of spinal cord herniation is an option that does not preclude symptomatic improvement in patients with idiopathic spinal cord herniation.
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Affiliation(s)
- Ritam Ghosh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lohit Velagapudi
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Thiago S Montenegro
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Glenn A Gonzalez
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Aria Mahtabfar
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Srinivas Prasad
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Jack Jallo
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joshua Heller
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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13
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Hines K, Wilt ZT, Franco D, Mahtabfar A, Elmer N, Gonzalez GA, Montenegro TS, Velagapudi L, Patel PD, Detweiler M, Fatema U, Schroeder GD, Harrop J. Long-segment posterior cervical decompression and fusion: does caudal level affect revision rate? J Neurosurg Spine 2021; 35:1-7. [PMID: 33892477 DOI: 10.3171/2020.10.spine201385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior cervical decompression and fusion (PCDF) is a commonly performed procedure to address cervical myelopathy. A significant number of these patients require revision surgery for adjacent-segment disease (ASD) or pseudarthrosis. Currently, there is no consensus among spine surgeons on the inclusion of proximal thoracic spine instrumentation. This study investigates the benefits of thoracic extension in long-segment cervical fusions and the potential drawbacks. The authors compare outcomes in long-segment subaxial cervical fusion for degenerative cervical myelopathy with caudal vertebral levels of C6, C7, and T1. METHODS A retrospective analysis identified 369 patients who underwent PCDF. Patients were grouped by caudal fusion level. Reoperation rates for ASD and pseudarthrosis, infection, and blood loss were examined. Data were analyzed with chi-square, 1-way ANOVA, and logistic regression. RESULTS The total reoperation rate for symptomatic pseudarthrosis or ASD was 4.8%. Reoperation rates, although not significant, were lower in the C3-6 group (2.6%, vs 8.3% for C3-7 and 3.8% for C3-T1; p = 0.129). Similarly, rates of infection were lower in the shorter-segment fusion without achieving statistical significance (2.6% for C3-6, vs 5.6% for C3-7 and 5.5% for C3-T1; p = 0.573). The mean blood loss was documented as 104, 125, and 224 mL for groups 1, 2, and 3, respectively (p < 0.001). CONCLUSIONS Given the lack of statistical difference in reoperation rates for long-segment cervical fusions ending at C6, C7, or T1, shorter fusions in high-risk surgical candidates or elderly patients may be performed without higher rates of reoperation.
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Affiliation(s)
- Kevin Hines
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Zachary T Wilt
- 2Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Daniel Franco
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Aria Mahtabfar
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Nicholas Elmer
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Glenn A Gonzalez
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Thiago S Montenegro
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Lohit Velagapudi
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Parthik D Patel
- 2Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Maxwell Detweiler
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Umma Fatema
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
| | - Gregory D Schroeder
- 2Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - James Harrop
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia; and
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14
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Abstract
STUDY DESIGN Narrative Review. OBJECTIVES The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement. METHODS We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive. RESULTS We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing. CONCLUSIONS In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.
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Affiliation(s)
- Lucas R. Philipp
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA,Lucas R. Philipp, Thomas Jefferson University, 909 Walnut St., 3 rd Floor, Department of Neurosurgery, Philadelphia, PA 19107, USA.
| | - Adam Leibold
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Aria Mahtabfar
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thiago S. Montenegro
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Glenn A. Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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15
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Hughes LP, Largoza G, Montenegro TS, Matias CM, Stefanelli A, Curtis MT, Harrop JS. Intradural extramedullary capillary hemangioma of the cauda equina: case report of a rare spinal tumor. Spinal Cord Ser Cases 2021; 7:21. [PMID: 33741893 PMCID: PMC7979701 DOI: 10.1038/s41394-021-00383-9] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/28/2021] [Accepted: 02/09/2021] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Intradural extramedullary capillary hemangiomas of the cauda equina are exceedingly rare, with only 20 previous cases reported. In the adult population, these tumors are rare and can arise in the central and peripheral nervous systems from the dura or spinal nerve roots. Intradural capillary hemangiomas of the cauda equina can yield symptoms such as lower extremity weakness, pain, and bladder and bowel dysfunction. The clinical symptomology and surgical management of this rare spinal lesion are reviewed in this case report. CASE PRESENTATION A 50-year-old male presented with progressive bilateral lower extremity weakness for 2 years, with recent bladder and bowel dysfunction. On physical exam, strength was symmetrically impaired in both lower extremities. Pre-operative magnetic resonance imaging (MRI) of the lumbar spine demonstrated a gadolinium-enhanced intradural lesion at the L4 level. Laminectomy was performed and the lesion was resected. Histopathological analysis determined that the tumor demonstrated features consistent with a capillary hemangioma. DISCUSSION Clinically, patients with capillary hemangiomas of the cauda equina present with space-occupying compressive deficits, including progressive low back and lower extremity pain, motor deficits, paresthesias, sensory loss, and bowel and bladder dysfunction. Acute presentation can transpire following a hemorrhagic episode, although this is more associated with cavernous rather than capillary hemangiomas. Our patient demonstrated non-acute, progressive weakness, and late-onset bladder and bowel dysfunction. This report demonstrates that this rare lesion should be included in the differential diagnosis of cauda equina lesions.
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Affiliation(s)
- Liam P Hughes
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| | - Garrett Largoza
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Thiago S Montenegro
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Caio M Matias
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Anthony Stefanelli
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Mark T Curtis
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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16
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Harrop J, Emes A, Chitale A, Wu C, Al Saiegh F, Stricsek G, Gonzalez GA, Jallo J, Heller J, Hines K, Philipp L, Thalheimer S, Prasad SK, Montenegro TS, Fatema U, Sharan A. Are Guidelines Important? Results of a Prospective Quality Improvement Lumbar Fusion Project. Neurosurgery 2021; 89:77-84. [PMID: 33729535 DOI: 10.1093/neuros/nyab062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/26/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND United States (U.S.) healthcare is a volume-based inefficient delivery system. Value requires the consideration of quality, which is lacking in most healthcare disciplines. OBJECTIVE To assess whether patients who met specific evidence-based medicine (EBM)-based criteria preoperatively for lumbar fusion would achieve higher rates of achieving the minimal clinical important difference (MCID) than those who did not meet the EBM indications. METHODS All elective lumbar fusion cases, March 2018 to August 2019, were prospectively evaluated and categorized based on EBM guidelines for surgical indications. The MCID was defined as a reduction of ≥5 points in Oswestry Disability Index (ODI). Multiple logistic regression identified multivariable-adjusted odds ratio of EBM concordance. RESULTS A total of 325 lumbar fusion patients were entered with 6-mo follow-up data available for 309 patients (95%). The median preoperative ODI score was 24.4 with median 6-mo improvement of 7.0 points (P < .0001). Based on ODI scores, 79.6% (246/309) improved, 3.8% (12/309) had no change, and 16% (51/309) worsened. A total of 191 patients had ODI improvement reaching the MCID. 93.2% (288/309) cases were EBM concordant, while 6.7% (21/309) were not.In multivariate analysis, EBM concordance (P = .0338), lower preoperative ODI (P < .001), lower ASA (American Society of Anesthesiologists) (P = .0056), and primary surgeries (P = .0004) were significantly associated with improved functional outcome. EBM concordance conferred a 3.04 (95% CI 1.10-8.40) times greater odds of achieving MCID in ODI at 6 mo (P = .0322), adjusting for other factors. CONCLUSION This analysis provides validation of EBM guideline criteria to establish optimal patient outcomes. The EBM concordant patients had a greater than 3 times improved outcome compared to those not meeting EBM fusion criteria.
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Affiliation(s)
- James Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexandra Emes
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ameet Chitale
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Chengyuan Wu
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Geoffrey Stricsek
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Glenn A Gonzalez
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jack Jallo
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Josh Heller
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kevin Hines
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Lucas Philipp
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Sara Thalheimer
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Srinivas K Prasad
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thiago S Montenegro
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Umma Fatema
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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17
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Montenegro TS, Hines K, Gonzalez GA, Fatema U, Partyka PP, Thalheimer S, Harrop J. How accurate is the neurosurgery literature? A review of references. Acta Neurochir (Wien) 2021; 163:13-18. [PMID: 32964271 DOI: 10.1007/s00701-020-04576-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The reference list is an important part of academic manuscripts. The goal of this study is to evaluate the reference accuracy in the field of neurosurgery. METHODS This study examines four major peer-reviewed neurosurgery journals, chosen based on their clinical impact factor: Neurosurgery, J Neurosurg, World Neurosurg, and Acta Neurochir. For each of the four journals, five articles from each of the journal's 12 issues published in 2019 were randomly selected using an online generator. This resulted in a total of 240 articles, 60 from each journal. Additionally, from each article's list of references, one reference was again randomly selected and checked for a citation or quotation error. The chi-square test was used to analyze the association between the occurrence of citation and quotation errors and the presence of hypothesized risk factors that could impact reference accuracy. RESULTS 62.1% of articles had a minor citation error, 8.33% had a major citation error, 12.1% had a minor quotation error, and 5.8% of articles had a major quotation error. Overall, Acta Neurochir presented with the fewest quotation errors compared with the other journals evaluated. The only association between the frequency of errors and potential markers of reference mistakes was with the length of the bibliography. Surprisingly, this correlation indicated that the articles with longer reference lists had fewer citation errors (p < 0.01). Statistical significance was found between the occurrence of citation errors and the journals of publication (p < 0.01). CONCLUSIONS In order to advance medical treatment and patient care in neurosurgery, detailed documentation and attention to detail are necessary. The results from this analysis illustrate that improved reference accuracy is required.
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18
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Abstract
OBJECTIVE The references list is an important part of a scientific article that serves to confirm the accuracy of the authors' statements. The goal of this study was to evaluate the reference accuracy in the field of spine surgery. METHODS Four major peer-reviewed spine surgery journals were chosen for this study based on their subspecialty clinical impact factors. Sixty articles per journal were selected from 12 issues each of The Spine Journal, Spine, and Journal of Neurosurgery: Spine, and 40 articles were selected from 8 issues of Global Spine Journal, for a total of 220 articles. All the articles were published in 2019 and were selected using computer-generated numbers. From the references list of each article, one reference was again selected by using a computer-generated number and then checked for citation or quotation errors. RESULTS The results indicate that 84.1% of articles have a minor citation error, 4.5% of articles have a major citation error, 9.5% of articles have a minor quotation error, and 9.1% of articles have a major quotation error. Journal of Neurosurgery: Spine had the fewest citation errors compared with the other journals evaluated in this study. Using chi-square analysis, no association was determined between the occurrence of errors and potential markers of reference mistakes. Still, statistical significance was found between the occurrence of citation errors and the spine journals tested. CONCLUSIONS In order to advance medical treatment and patient care in spine surgery, detailed documentation and attention to detail are necessary. The results from this study illustrate that improved reference accuracy is required.
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Affiliation(s)
- Thiago S Montenegro
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Kevin Hines
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Paul P Partyka
- 2School of Osteopathic Medicine, Rowan University, Stratford, New Jersey; and
- 3Department of Biomedical Engineering, Rowan University, Glassboro, New Jersey
| | - James Harrop
- 1Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
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19
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Mouchtouris N, Lavergne P, Montenegro TS, Gonzalez G, Baldassari M, Sharan A, Jabbour P, Harrop J, Rosenwasser R, Evans JJ. Telemedicine in Neurosurgery: Lessons Learned and Transformation of Care During the COVID-19 Pandemic. World Neurosurg 2020; 140:e387-e394. [PMID: 32512241 PMCID: PMC7274123 DOI: 10.1016/j.wneu.2020.05.251] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 05/26/2020] [Accepted: 05/28/2020] [Indexed: 11/02/2022]
Abstract
BACKGROUND Before the COVID-19 pandemic, telemedicine utilization was mostly used for postoperative visits only in neurosurgery. Shelter-in-place measures led the rapid expansion of telemedicine to address the needs of the neurosurgical patient population. Our goal is to determine the extent of adoption of telemedicine across tumor, vascular, spine, and function neurosurgery and utilization for new patient visits. METHODS A single-center retrospective cohort study of patients who received neurosurgical care at a tertiary academic center from February to April 2020 was conducted. Patients evaluated from March to April 2019 were included for comparison. A total of 10,746 patients were included: 1247 patients underwent surgery, 8742 were seen in clinic via an in-person outpatient visit, and 757 were assessed via telemedicine during the study period. RESULTS A 40-fold increase in the use of telemedicine was noted after the shelter-in-place measures were initiated with a significant increase in the mean number of patients evaluated via telemedicine per week across all divisions of neurosurgery (4.5 ± 0.9 to 180.4 ± 13.9, P < 0.001). The majority of telemedicine appointments were established patient visits (61.2%), but the proportion of new patient visits also significantly increased to an average of 8.2 ± 5.3 per week across all divisions. CONCLUSIONS Use of telemedicine drastically increased across all 4 divisions within neurosurgery with a significant increase in online-first encounters in order to meet the needs of our patients once the shelter-in-place measures were implemented. We provide a detailed account of the lessons learned and discuss the anticipated role of telemedicine in surgical practices once the shelter-in-place measures are lifted.
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Affiliation(s)
- Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Lavergne
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Thiago S Montenegro
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Glenn Gonzalez
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Michael Baldassari
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ashwini Sharan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - James Harrop
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - James J Evans
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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