Publications by authors named "Alexander J Schupper"

64 Publications

Evaluation of differences across age groups in the incidence, severity, and recovery of concussion in adolescent student-athletes from 2009 to 2019.

J Neurosurg Pediatr 2022 Jul 29:1-9. Epub 2022 Jul 29.

1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York.

Objective: Concussion incidence is known to be highest in children and adolescents; however, there is conflicting evidence about the effect of age on concussion risk and recovery within the adolescent age range. The heterogeneity of results may be partially due to the use of age groupings based on convenience, making comparisons across studies difficult. This study evaluated the independent effect of age on concussion incidence, severity, and recovery in student-athletes aged 12-18 years using cluster analysis to define groupings.

Methods: Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores of 11,403 baseline tests and 4922 postinjury tests were used to calculate the incidence rates for adolescent student-athletes grouped into 3 age bands (12-13, 14-15, and 16-18 years of age) on the basis of clustering analysis. The recently created Severity Index was used to compare concussion severity between groups. Follow-up tests for subjects who sustained a concussion were used to evaluate recovery time. The chi-square test and 1-way ANOVA were used to compare differences in demographic characteristics and concussion incidence, severity, and recovery. Multivariable logistic and linear regressions were used to evaluate the independent effects of age on concussion incidence and severity, respectively. Multivariable Cox hazard regression was used to evaluate differences in recovery time. Further analyses were conducted to directly compare findings across studies on the basis of the age groupings used in prior studies.

Results: Multivariable regression analyses demonstrated that the 14- to 15-year-old age group had a significantly higher concussion incidence than both the 12- to 13-year-old (14- to 15-year-old group vs 12- to 13-year-old group, OR 1.57, 95% CI 1.16-2.17, p = 0.005) and 16- to 18-year-old (16- to 18-year-old group vs 14- to 15-year-old group, OR 0.79, 95% CI 0.69-0.91, p = 0.0008) age groups. There was no difference in incidence between the 12- to 13-year-old and 16- to 18-year-old groups (16- to 18-year group vs 12- to 13-year group, OR 1.26, 95% CI 0.93-1.72, p = 0.15). There were also no differences in concussion severity or recovery between any groups.

Conclusions: This study found that concussion incidence was higher during mid-adolescence than early and late adolescence, suggesting a U-shaped relationship between age and concussion risk over the course of adolescence. Age had no independent effect on concussion severity or recovery in the 12- to 13-, 14- to 15-, and 16- to 18-year-old groups. Further analysis of the various age groups revealed that results may vary significantly with minor changes to groupings, which may explain the divergent results in the current literature on this topic. Thus, caution should be taken when interpreting the results of this and all similar studies, especially when groupings are based on convenience.
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http://dx.doi.org/10.3171/2022.6.PEDS22127DOI Listing
July 2022

Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review Protocol.

Methods Protoc 2022 Jun 5;5(3). Epub 2022 Jun 5.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.

Spine surgery patients with a history of organ transplantation are a complex population due to their unique anesthetic considerations, immunologic profiles, drug interactions, and potential organ dysfunction. It is common for these patients to develop neck/back pain and pathology that warrants surgical intervention. However, there is a relative dearth of literature examining their outcomes and clinical considerations. The purpose of this protocol is to investigate their clinical outcomes following spine surgery and medical management. We perform a systematic literature search using PRISMA-ScR guidelines to include case reports, cohort studies, and retrospective analyses. The search terms include kidney, liver, heart, pancreas, lung, and bone marrow for transplants of interest and contain an extensive list of terms covering spine surgery. The search is conducted using Medline, Embase, and the Cochrane Central Register of Controlled Trials. A thorough examination of titles and abstracts is performed followed by data extraction. The data points include patient demographics, past medical history, spine procedural information, and clinical outcomes. This systematic review will aid clinicians in identifying demographics, medical management, and clinical outcomes for spine surgery patients with a previous organ transplant. These findings will highlight the gaps in the knowledge of this complex population and stimulate further research.
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http://dx.doi.org/10.3390/mps5030047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9229861PMC
June 2022

Effects of a history of headache and migraine treatment on baseline neurocognitive function in young athletes.

J Headache Pain 2022 Jun 3;23(1):62. Epub 2022 Jun 3.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective/background: Despite the prevalence of concussions in young athletes, the impact of headaches on neurocognitive function at baseline is poorly understood. We analyze the effects of a history of headache treatment on baseline ImPACT composite scores in young athletes.

Methods: A total of 11,563 baseline ImPACT tests taken by 7,453 student-athletes ages 12-22 between 2009 and 2019 were reviewed. The first baseline test was included. There were 960 subjects who reported a history of treatment for headache and/or migraine (HA) and 5,715 controls (CT). The HA cohort included all subjects who self-reported a history of treatment for migraine or other type of headache on the standardized questionnaire. Chi-squared tests were used to compare demographic differences. Univariate and multivariate regression analyses were used to assess differences in baseline composite scores between cohorts while controlling for demographic differences and symptom burden.

Results: Unadjusted analyses demonstrated that HA was associated with increased symptoms (β=2.30, 95% CI: 2.18-2.41, p<.0001), decreased visual memory (β=-1.35, 95% CI: -2.62 to -0.43, p=.004), and increased visual motor speed (β=0.71, 95% CI: 0.23-1.19, p=.004) composite scores. Baseline scores for verbal memory, reaction time, and impulse control were not significantly different between cohorts. Adjusted analyses demonstrated similar results with HA patients having greater symptom burden (β=1.40, 95% CI: 1.10-1.70, p<.0001), lower visual memory (β=-1.25, 95% CI: -2.22 to -0.27, p=.01), and enhanced visual motor speed (β=0.60, 95% CI: 0.11-1.10, p=.02) scores.

Conclusion: HA affected symptom, visual motor speed, and visual memory ImPACT composite scores. Visual memory scores and symptom burden were significantly worse in the HA group while visual motor speed scores were better, which may have been due to higher stimulant use in the HA group. The effects of HA on visual motor speed and visual memory scores were independent of the effects of the increased symptom burden.
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http://dx.doi.org/10.1186/s10194-022-01432-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9164363PMC
June 2022

Subspecialty and Training Preferences for U.S. Neurosurgery Faculty with International Training.

World Neurosurg 2022 Aug 2;164:e326-e334. Epub 2022 May 2.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Academic neurosurgeons with international medical training play a large role in the U.S. neurosurgical workforce. We aimed to compare U.S.-trained neurosurgeons with internationally trained neurosurgeons to reveal differences in subspecialty preferences and training opportunities abroad.

Methods: We identified 1671 neurosurgeons from 115 Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgical residency programs. Data on demographics, institution characteristics, and chosen subspecialty were collected, and faculty were divided based on location of training. Univariate analysis and multivariable logistic regression compared faculty characteristics between training locations.

Results: Compared with the U.S. medical school + U.S. residency group, the international medical graduate + U.S. residency group was more likely to subspecialize in oncology/skull base and vascular neurosurgery and complete a fellowship in the United States or internationally (P < 0.05). The international medical graduate + international residency group was more likely to subspecialize in oncology/skull base neurosurgery, more likely to complete an international fellowship, and less likely to practice general neurosurgery (P < 0.05). Neurosurgeons in pediatrics, radiosurgery, and vascular subspecialties were more likely to receive fellowship training in any location (P < 0.05). Additionally, functional neurosurgeons were more likely to complete fellowships internationally, spinal neurosurgeons were less likely to pursue international fellowships, and peripheral nerve neurosurgeons were more likely to have dual fellowship training in both the United States and abroad (P < 0.05).

Conclusions: International medical training affected subspecialty choice and fellowship training. Internationally trained neurosurgeons more often specialized in oncology and vascular neurosurgery. Functional neurosurgeons were more likely to complete international fellowships, spine neurosurgeons were less likely to complete international fellowships, and peripheral nerve neurosurgeons more often had both U.S. and international fellowships.
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http://dx.doi.org/10.1016/j.wneu.2022.04.105DOI Listing
August 2022

Multilevel Cervical Arthroplasty: Expanding Indications.

World Neurosurg 2022 Aug 20;164:116. Epub 2022 Apr 20.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

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http://dx.doi.org/10.1016/j.wneu.2022.04.076DOI Listing
August 2022

MIS-TLIF Procedure is Improving With Experience: Systematic Review of the Learning Curve Over the Last Decade.

Clin Spine Surg 2022 Mar 31. Epub 2022 Mar 31.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY.

Study Design: This was a systematic review.

Objective: This review evaluates the minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) learning curve in the literature and compares outcomes during and after completing the curve.

Summary Of Background Data: MIS-TLIF are performed for various spine conditions. Proponents cite improved clinical outcomes while critics highlight the steep learning curve to attain proficiency.

Methods: Literature searches on Medline and Embase utilized relevant subject headings and keywords. Manuscripts reporting learning curve statistics were included. Monotonic trends of operative duration were assessed with Mann-Kendall nonparametric testing.

Results: Nine studies met inclusion criteria. Number of patients ranged from 26 to 150 (average 83.2, median of 86). Commonly reported metrics included number of procedures to complete the curve, operative duration, blood loss, ambulation time, length of stay, complication rate, follow-up visual analogue scale (VAS) for back and leg pain, and fusion rate. Various methods were employed to determine number of cases to complete the curve, all involving operative duration. Number of cases ranged from 14 to 44. A significant negative trend for operative duration of cases during the learning curve (τ=-0.733, P=0.039) was found over the years that studies were published. Initial complication rates varied from 6.8% to 23.8%. Initial VAS-back and VAS-leg ranged from 0.8 to 2.9 and 0.5 to 2.3, respectively. While definitions of "good" fusion varied, fusion rates meeting Bridwell grade I or II during the learning curve ranged from 84.0% to 95.2%.

Conclusions: Surgeons in their learning curve have become faster at the MIS-TLIF procedure. Clinical outcomes including postoperative pain and fusion rates showed satisfactory results, but surgeons learning the procedure should take measures to minimize complications in early cases, such as utilizing novel navigation technology or supervision from more experienced surgeons. Learning curve research methodology could benefit from standardization.
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http://dx.doi.org/10.1097/BSD.0000000000001331DOI Listing
March 2022

In Reply to the Letter to the Editor Regarding "Bibliometric Evaluation of U.S. Neurosurgery Subspecialties and Academic Rank Using RCR Index".

World Neurosurg 2022 03;159:246-247

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

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http://dx.doi.org/10.1016/j.wneu.2021.12.120DOI Listing
March 2022

Prolonged Brace Treatment Does Not Result in Improved Acetabular Indices in Infantile Dislocated Hips.

J Pediatr Orthop 2022 May-Jun 01;42(5):e409-e413

The Hospital for Sick Children, Toronto, Ontario, Canada.

Background: The Pavlik harness (PH) is commonly used to treat infantile dislocated hips. However, significant variability exists in the duration of brace treatment after successful reduction of the dislocated hip. The purpose of this study was to evaluate the effect of prescribed time in brace on acetabular index (AI) at two years of age using a prospective, international, multicenter database.

Methods: We retrospectively studied prospectively enrolled infants with at least 1 dislocated hip that were initially treated with a PH and had a recorded AI at 2-year follow-up. Subjects were treated at 1 of 2 institutions. Institution 1 used the PH until they observed normal radiographic acetabular development. Institution 2 followed a structured shorter brace treatment protocol. Hip dislocation was defined as <30% femoral head coverage at rest on the pretreatment ultrasound or International Hip Dysplasia Institute (IHDI) grade III or IV on the pretreatment radiograph.

Results: Fifty-three hips met our inclusion criteria. Hips from Institution 1 were treated with a brace ×3 longer than hips from institution 2 (adjusted mean 8.9±1.3 vs. 2.6±0.2 mo) (P<0.001). Institution 1 had an 88% success rate and institution 2 had an 85% success rate at achieving hip reduction (P=0.735). At 2-year follow-up, we observed no significant difference in AI between Institution 1 (adjusted mean 25.6±0.9 degrees) compared with Institution 2 (adjusted mean 23.5±0.8 degrees) (P=0.1). However, 19% of patients from Institution 1 and 44% of patients from Institution 2 were at or below the 50th percentile of previously published age-matched and sex-matched AI normal data (P=0.049). Also, 27% (7/26) of hips from Institution 1 had significant acetabular dysplasia (more than 2 SD from the mean), compared with a 22% (6/27) from Institution 2 (P=0.691). We found no correlation between age at initiation of bracing and AI at 2-year follow-up (P=0.071).

Conclusions: The PH brace can successfully treat dislocated infant hips, however, prolonged brace treatment was not found to result in improved acetabular development at 2-year follow-up.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BPO.0000000000002110DOI Listing
April 2022

High altitude modulates concussion incidence, severity, and recovery in young athletes.

Brain Inj 2022 05 3;36(6):733-739. Epub 2022 Feb 3.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA.

Background: High altitude may affect concussion, but prior studies are limited . We tested whether high altitude affects sport-related concussion (SRC) incidence, severity, and recovery.

Methods: Twenty-five thousand eight hundred fifteen baseline and post-injury Immediate Post-Concussion Assessment and Cognitive Testing results were compiled from Florida and Colorado, low (27 m or 62 m) and high (1,640 m or 1,991 m) altitude locations, respectively. Incidence, severity, and recovery of injury were compared between altitudes.

Results: High altitude was associated with increased suspected concussion incidence (adjusted OR, 2.04 [95% CI, 1.86 to 2.24]; < .0001). However, high altitude was associated with lower concussion severity measured by Severity Index (SI) (adjusted OR, 0.42 [95% CI, 0.37 to 0.49]; < .0001). High altitude was associated with decreased recovery from post-concussive symptoms in the migraine (β, -2.72 [95% CI, -3.31 to -2.13]; P < .0001), cognitive (β, -1.88 [95% CI, -2.40 to -1.36]; P < .0001), and sleep symptom clusters (β, -0.30 [95% CI, -0.52 to -0.08]; P = .007). Athletes with initial SI≥8 showed prolonged neurocognitive dysfunction at high altitude (HR, 1.38 [95% CI, 1.06 to 1.81]; P = .02).

Conclusions: High altitude was associated with increased suspected concussions and prolonged recovery but less severe initial injury.
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http://dx.doi.org/10.1080/02699052.2022.2035435DOI Listing
May 2022

Seasonal Effects on Surgical Site Infections Following Spine Surgery.

World Neurosurg 2022 May 29;161:e174-e182. Epub 2022 Jan 29.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Studies investigating seasonality as a risk factor for surgical site infections (SSIs) after spine surgery show mixed results. This study used national data to analyze seasonal effects on spine surgery SSIs.

Methods: National Surgical Quality Improvement Program data (2011-2018) were queried for posterior cervical fusions (PCFs), cervical laminoplasties, posterior lumbar fusions (PLFs), lumbar laminectomies, and deformity surgeries. Patients aged >89 and procedures for tumors, fractures, infections, and nonelective indications were excluded. Patients were divided into warm (admitted April-September) and cold (admitted October-March) seasonal groups. End points were SSIs and reoperations for wound débridement/drainage. Stratified analyses were performed by surgery type and pre-versus postdischarge infections.

Results: Overall (N = 208,291), SSIs were more likely in the warm season (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.08-1.23, P < 0.0001) and for PCFs (OR 1.40, 95% CI 1.08-1.80, P = 0.011), PLFs (OR 1.15, 95% CI 1.04-1.28, P = 0.006), and lumbar laminectomies (OR 1.13, 95% CI 1.03-1.25, P = 0.014). Postdischarge infections were also more likely in the warm season overall (OR 1.15, 95% CI 1.07-1.23, P < 0.0001) and for PCFs (OR 1.32, 95% CI 1.01-1.73, P = 0.041), PLFs (OR 1.14, 95% CI 1.03-1.27, P = 0.014), and lumbar laminectomies (OR 1.15, CI 1.04-1.27, P = 0.007). In-hospital infections were more likely during the warm season only for PCFs (OR 2.54, 95% CI 1.06-6.10, P = 0.037). Reoperations for infection were more likely during the warm season for PLFs (OR 1.29, 95% CI 1.08-1.54, P = 0.005).

Conclusions: PCF, PLF, and lumbar laminectomy performed during the warm season had significantly higher odds of SSI, especially postdischarge SSIs. Reoperation rates for wound management were significantly increased during the warm season for PLFs. Identifying seasonal causes merits further investigation and may influence surgeon scheduling and expectations.
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http://dx.doi.org/10.1016/j.wneu.2022.01.100DOI Listing
May 2022

Incidence and Severity of Concussions Among Young Soccer Players Based on Age, Sex, and Player Position.

Orthop J Sports Med 2022 Jan 17;10(1):23259671211059216. Epub 2022 Jan 17.

Neurosurgery Department, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Previously studied risk factors for sports-related concussion in soccer players include sex, age, and player position. However, prior studies were limited in number, they reported conflicting results, and most did not assess initial concussion severity.

Purpose/hypothesis: The purpose of this study was to conduct an in-depth analysis of soccer players across key demographic groups (sex, age, position) for both concussion incidence and severity. It was hypothesized that concussion incidence and severity would be higher among male players, players aged ≥17 years, and goalkeepers.

Study Design: Cohort study; Level of evidence, 3.

Methods: The authors analyzed baseline and postinjury ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) scores for athletes aged 12 to 22 years between July 2009 and June 2019. Players were assigned to an age group based on when they had their most recent baseline test. Concussion incidence and concussion severity index were compared using tests and multivariate logistic regression.

Results: For 1189 individuals who reported soccer as their primary sport, 1032 contributed 1754 baseline ImPACT tests (some individuals had multiple baseline tests), whereas 445 individuals were suspected of sustaining a concussion and then referred for a postinjury 1 test. Of these players, 254 (24.6%) had both a baseline and a postinjury test and were analyzed for concussion severity. Linear regression showed that forwards had a lower incidence of ImPACT-proxied concussions than goalkeepers had ( = .008). Female players had a significantly higher incidence of ImPACT concussions compared with male players (mean, 0.07 [female] vs 0.04 [male] concussions per person-year; = .05). Players in the ≥17-year age group had a higher incidence of ImPACT concussions than players in the 15- to 16-year age group ( = .04), although the 15- to 16-year age group had more severe concussions than the ≥17-year age group (mean severity index, 2.91 [age 15-16 years] vs 1.73 [age ≥17 years]; = .001).

Conclusion: Female soccer players experienced a higher incidence of concussion than did male players, and goalkeepers experienced a greater incidence of ImPACT concussions than did forwards. Players of both sexes and all positions in the 15- to 16-year age group showed increased initial concussion severity compared with the ≥17-year age group, despite a lower comparative incidence of ImPACT concussions. Further study is needed to understand whether sex and player position affect concussion severity.
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http://dx.doi.org/10.1177/23259671211059216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8785311PMC
January 2022

Intraoperative Navigation in Spine Surgery: Effects on Complications and Reoperations.

World Neurosurg 2022 Apr 13;160:e404-e411. Epub 2022 Jan 13.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA.

Introduction: Intraoperative navigation during spine surgery improves pedicle screw placement accuracy. However, limited studies have correlated the use of navigation with clinical factors, including operative time and safety. In the present study, we compared the complications and reoperations between surgeries with and without navigation.

Methods: The National Surgical Quality Improvement Project database was queried for posterior cervical and lumbar fusions and deformity surgeries from 2011 to 2018 and divided by navigation use. Patients aged >89 years, patients with deformity aged <25 years, and patients undergoing surgery for tumors, fractures, infections, or nonelective indications were excluded. The demographics and perioperative factors were compared via univariate analysis. The outcomes were compared using multivariable logistic regression adjusting for age, sex, body mass index, American Society of Anesthesiologists class, surgical region, and multiple treatment levels. The outcomes were also compared stratifying by revision status.

Results: Navigation surgery patients had had higher American Society of Anesthesiologists class (P < 0.0001), more multiple level surgeries (P < 0.0001), and longer operative times (P < 0.0001). The adjusted analysis revealed that navigated lumbar surgery had lower odds of complications (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.77-0.90; P < 0.0001), blood transfusion (OR, 0.79; 95% CI, 0.72-0.87; P < 0.0001), and wound debridement and/or drainage (OR, 0.66; 95% CI, 0.44-0.97; P = 0.04) compared with non-navigated lumbar surgery. Navigated cervical fusions had increased odds of transfusions (OR, 1.53; 95% CI, 1.06-2.23; P = 0.02). Navigated primary fusion had decreased odds of complications (OR, 0.91; 95% CI, 0.85-0.98; P = 0.01). However, no differences were found in revisions (OR, 0.89; 95% CI, 0.69-1.14; P = 0.34).

Conclusions: Navigated surgery patients experienced longer operations owing to a combination of the time required for navigation, more multilevel procedures, and a larger comorbidity burden, without differences in the incidence of infection. Fewer complications and wound washouts were required for navigated lumbar surgery owing to a greater proportion percentage of minimally invasive cases. The combined use of navigation and minimally invasive surgery might benefit patients with the proper indications.
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http://dx.doi.org/10.1016/j.wneu.2022.01.035DOI Listing
April 2022

Vertebral Column Shortening for Recurrent Tethered Cord Syndrome.

World Neurosurg 2022 01;157:240-241

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

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http://dx.doi.org/10.1016/j.wneu.2021.09.129DOI Listing
January 2022

Clinical Trials in Spinal Tumors: A Two-Decade Review.

World Neurosurg 2022 May 30;161:e39-e53. Epub 2021 Nov 30.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: Clinical trials are essential for assessing the advancements in spine tumor therapeutics. The purpose of the present study was to characterize the trends in clinical trials for primary and metastatic tumor treatment during the past 2 decades.

Methods: The ClinicalTrials.gov database was queried using the search term "spine" for all interventional studies from 1999 to 2020 with the categories of "cancer," "neoplasm," "tumor," and/or "metastasis." The tumor type, phase data, enrollment numbers, and home institution country were recorded. The sponsor was categorized as an academic institution, industry, government, or other and the intervention type as procedure, drug, device, radiation therapy, or other. The frequency of each category and the cumulative frequency during the 20-year period were calculated.

Results: A total of 106 registered trials for spine tumors were listed. All, except for 2, that had begun before 2008 had been completed. An enrollment of 51-100 participants (29.8%) was the most common, and most were phase II studies (54.4%). Most of the studies had examined metastatic tumors (58.5%), and the number of new trials annually had increased 3.4-fold from 2009 to 2020. Most of the studies had been conducted in the United States (56.4%). The most common intervention strategy was radiation therapy (32.1%), although from 2010 to 2020, procedural studies had become the most frequent (2.4/year). Most of the studies had been sponsored by academic institutions (63.2%), which during the 20-year period had sponsored 3.2-fold more studies compared with the industry partners.

Conclusions: The number of clinical trials for spine tumor therapies has rapidly increased during the past 15 years, owing to studies at U.S. academic medical institutions investigating radiosurgery for the treatment of metastases. Targeted therapies for tumor subtypes and sequelae have updated international best practices.
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http://dx.doi.org/10.1016/j.wneu.2021.11.101DOI Listing
May 2022

The Impact of American Society of Anesthesiologists Status on Cost of Care and Length of Stay Following Posterior Cervical Decompression and Fusion.

World Neurosurg 2022 May 29;161:e54-e60. Epub 2021 Nov 29.

Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.

Background: Increased posterior cervical decompression and fusion (PCDF) procedures over the past decade have raised the prospect of bundled payment plans. The American Society of Anesthesiologists (ASA) Physical Status Classification system may enable accurate estimation of health care costs, length of stay (LOS), and other postoperative outcomes in patients undergoing PCDF.

Methods: Low (I and II) versus high (III and IV) ASA class was used to evaluate 971 patients who underwent PCDF between 2008 and 2016 at a single institution. Demographics were compared using univariate analysis. Cost of care, LOS, and postoperative complications were compared using multivariable logistic and linear regression, controlling for sex, age, length of surgery, and number of segments fused.

Results: The high ASA class cohort was older (mean age 62 years vs. 55 years, P < 0.0001) and had higher Elixhauser comorbidity index scores (P < 0.0001). ASA class was independently associated with longer LOS (2.1 days, 95% confidence interval [CI] 1.3-2.9, P < 0.0001) and higher cost ($2936, 95% CI $1457-$4415, P < 0.0001). Patients with high ASA class were more likely to have a nonhome discharge (3.9, 95% CI 2.8-5.6, P < 0.0001), delayed extubation (3.2, 95% CI 1.4-7.3, P = 0.006), intensive care unit stay (2.4, 95% CI 1.5 3.7, P = 0.0001), in-hospital complications (1.5, 95% CI 1.0-2.2, P = 0.03), and 30-day (3.2, 95% CI 1.5-6.8, P = 0.003) and 90-day (3.2, 95% CI 1.8-5.7, P = 0.0001) readmission.

Conclusions: High ASA class is strongly associated with increased costs, LOS, and adverse outcomes following PCDF and could be useful for preoperative prediction of these outcomes.
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http://dx.doi.org/10.1016/j.wneu.2021.11.100DOI Listing
May 2022

Bibliometric Evaluation of U.S. Neurosurgery Subspecialties and Academic Rank Using RCR Index.

World Neurosurg 2022 Feb 26;158:e138-e147. Epub 2021 Oct 26.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Introduction: Academic productivity, a key feature of academic neurosurgery, has been linked to academic rank, subspecialty, and institutional rank. Relative Citation Ratio (RCR) has emerged as a new metric of scholarly output that can make field-normalized comparisons between researchers, a feature unavailable in prior metrics such as h-index. Here we evaluate the influence of academic rank and neurosurgical subspecialties on RCR scores.

Methods: We identified 1640 academic neurosurgeons from 115 ACGME-accredited programs in the United States, along with their neurosurgical specialty and demographic information, using publicly available data. Mean RCR (m-RCR) and weighted RCR (w-RCR) for each neurosurgeon were queried from the iCite database, which included publications from 2002-2020. m-RCR and w-RCR scores were compared across subspecialties and academic rank using multivariable regression while controlling for demographic factors.

Results: Multivariable analysis indicated that academic neurosurgeons in general neurosurgery (P = 0.039) and pediatric neurosurgery (P = 0.003) had lower m-RCR scores than their peers in other subspecialties. w-RCR did not differ significantly among subspecialties. Higher academic rank was associated with increased m-RCR (P < 0.05) and w-RCR scores (P < 0.0001).

Conclusions: Professors have a higher m-RCR score relative to assistant professors, while general and pediatric neurosurgery were linked to lower m-RCR values. Although neurosurgical subspecialty choice did not influence w-RCR, a higher w-RCR score corresponded to a higher academic rank. Overall, the RCR metric can be utilized for field-normalized comparisons of faculty who differ in academic rank and subspecialty.
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http://dx.doi.org/10.1016/j.wneu.2021.10.148DOI Listing
February 2022

Impact of Psychiatric Illnesses and Selective Serotonin Reuptake Inhibitor Medications on Baseline Neurocognitive Testing.

Arch Clin Neuropsychol 2022 Feb;37(3):633-640

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Introduction: Neurocognitive tests are an integral component of sport-related concussion (SRC) workup. A history of psychiatric illness (HPI) is common among young athletes. Investigations of factors that influence athletes' baseline neurocognitive function are crucial for an accurate assessment of SRC.

Objective: In this study, we aim to elucidate the effect of HPI and selective-serotonin reuptake inhibitor (SSRI) medication use on baseline neurocognitive performance in young athletes.

Methods: We conducted a retrospective cross-sectional study of Immediate Post-Concussion Assessment and Cognitive Testing assessments. A total of 268 athletes with HPI and a control group of 6,364 athletes were included. The outcomes were total symptom score based on post-concussion symptom scale, verbal memory, visual memory, visual motor, reaction time, and impulse control scores with self-reported HPI status and SSRI use.

Results: Athletes with HPI had an elevated symptom score in both univariate analysis (p < .0001) and multivariate analysis (p < .0001). HPI influence on visual memory score was not robust to multivariate analysis (p = .24). Athletes with HPI who reported SSRI medication use had the same baseline neurocognitive performance as other athletes with HPI. HPI influences athletes' baseline neurocognitive performance by elevating symptom scores. HPI does not alter any of the objective neurocognitive composite scores in contrast to previous work.

Conclusions: Clinicians should consider the impact of HPI on baseline neurocognitive performance during the assessment of a suspected SRC. Additional research is required to bolster our findings on SSRI use and ascertain the effects of other drug classes on baseline neurocognitive performance.
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http://dx.doi.org/10.1093/arclin/acab087DOI Listing
February 2022

5-Aminolevulinic acid for enhanced surgical visualization of high-grade gliomas: a prospective, multicenter study.

J Neurosurg 2021 Oct 8:1-10. Epub 2021 Oct 8.

1Department of Neurological Surgery, Mount Sinai Health System, New York, New York.

Objective: Greater extent of resection (EOR) is associated with longer overall survival in patients with high-grade gliomas (HGGs). 5-Aminolevulinic acid (5-ALA) can increase EOR by improving intraoperative visualization of contrast-enhancing tumor during fluorescence-guided surgery (FGS). When administered orally, 5-ALA is converted by glioma cells into protoporphyrin IX (PPIX), which fluoresces under blue 400-nm light. 5-ALA has been available for use in Europe since 2010, but only recently gained FDA approval as an intraoperative imaging agent for HGG tissue. In this first-ever, to the authors' knowledge, multicenter 5-ALA FGS study conducted in the United States, the primary objectives were the following: 1) assess the diagnostic accuracy of 5-ALA-induced PPIX fluorescence for HGG histopathology across diverse centers and surgeons; and 2) assess the safety profile of 5-ALA FGS, with particular attention to neurological morbidity.

Methods: This single-arm, multicenter, prospective study included adults aged 18-80 years with Karnofsky Performance Status (KPS) score > 60 and an MRI diagnosis of suspected new or recurrent resectable HGG. Intraoperatively, 3-5 samples per tumor were taken and their fluorescence status was recorded by the surgeon. Specimens were submitted for histopathological analysis. Patients were followed for 6 weeks postoperatively for adverse events, changes in the neurological exam, and KPS score. Multivariate analyses were performed of the outcomes of KPS decline, EOR, and residual enhancing tumor volume to identify predictive patient and intraoperative variables.

Results: Sixty-nine patients underwent 5-ALA FGS, providing 275 tumor samples for analysis. PPIX fluorescence had a sensitivity of 96.5%, specificity of 29.4%, positive predictive value (PPV) for HGG histopathology of 95.4%, and diagnostic accuracy of 92.4%. Drug-related adverse events occurred at a rate of 22%. Serious adverse events due to intraoperative neurological injury, which may have resulted from FGS, occurred at a rate of 4.3%. There were 2 deaths unrelated to FGS. Compared to preoperative KPS scores, postoperative KPS scores were significantly lower at 48 hours and 2 weeks but were not different at 6 weeks postoperatively. Complete resection of enhancing tumor occurred in 51.9% of patients. Smaller preoperative tumor volume and use of intraoperative MRI predicted lower residual tumor volume.

Conclusions: PPIX fluorescence, as judged by the surgeon, has a high sensitivity and PPV for HGG. 5-ALA was well tolerated in terms of drug-related adverse events, and its application by trained surgeons in FGS for HGGs was not associated with any excess neurological morbidity.
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http://dx.doi.org/10.3171/2021.5.JNS21310DOI Listing
October 2021

Robotic-Assisted Digital Exoscope for Resection of Cerebral Metastases: A Case Series.

Oper Neurosurg (Hagerstown) 2021 11;21(6):436-444

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA.

Background: Surgical resection is the primary treatment for cerebral metastases with safe complete resection as the goal. The robotically assisted digital surgical exoscope is a novel system with advanced visualization methods with recent applications in neurosurgery.

Objective: To evaluate the outcomes for patients with cerebral metastases undergoing resection with the surgical exoscope.

Methods: Data were retrospectively collected from patients with cerebral metastases where resection was achieved with using the surgical exoscope from 2016 to 2020. Demographics, clinical, imaging, and operative and outcome findings were collected. The relationship between perioperative data and discharge disposition as well as progression-free survival (PFS) and 12 mo overall survival (OS) was assessed.

Results: A total of 31 patients (19 males) with a median patient age 63 yr (range 38-80) were included. Average pre- and postoperative volumes were 18.1 cc and 0.75 cc, respectively. Mean depth of the resected lesions was 0.6 cm (range 0-3.6 cm). Complete resection was achieved in 64.5% of patients. The mean extent of resection was 96.7%, with 71.0% achieving PFS at 6 mo. Overall PFS rate was 58.1% and the OS rate at 12 mo was 83.9%. Neurological complications included motor (35.5%) and sensory (12.9%) deficits, with 12 patients reporting no postoperative symptoms.

Conclusion: The surgical exoscope can delineate tumor tissues with high resolution, as shown by a gross total resection achieved for the majority of cases in our series. Postoperative complications and patient outcomes were similar to those reported with use of the operative microscope. Use of the exoscope can provide optimal visualization and delineation of cerebral metastases.
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http://dx.doi.org/10.1093/ons/opab356DOI Listing
November 2021

Comparison of Cost and Perioperative Outcome Profiles for Primary and Revision Posterior Cervical Fusion Procedures.

Spine (Phila Pa 1976) 2021 Oct;46(19):1295-1301

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY.

Study Design: Retrospective analysis.

Objective: To compare perioperative outcomes and hospitalization costs between patients undergoing primary or revision posterior cervical discectomy and fusion (PCDF).

Summary Of Background Data: While prior studies found differences in outcomes between primary and revision anterior cervical discectomy and fusion (ACDF), risk, and outcome profiles for posterior cervical revision procedures have not yet been elucidated.

Methods: Institutional records were queried for cases involving isolated PCDF procedures to evaluate preoperative characteristics and outcomes for patients undergoing primary versus revision PCDF between 2008 and 2016. The primary outcome was perioperative complications, while perioperative and resource utilization measures such as hospitalization length, required stay in the intensive care unit (ICU), direct hospitalization costs, and 30-day emergency department (ED) admissions were explored as secondary outcomes.

Results: One thousand one hundred twenty four patients underwent PCDF, with 218 (19.4%) undergoing a revision procedure. Patients undergoing revision procedures were younger (53.0 vs. 60.5 yrs), but had higher Elixhauser scores compared with the non-revision cohort. Revision cases tended to involve fewer spinal segments (3.6 vs. 4.1 segments) and shorter surgical durations (179.3 vs. 206.3 min), without significant differences in estimated blood loss. There were no significant differences in the overall complication rates (P = 0.20), however, the primary cohort had greater rates of required ICU stays (P = 0.0005) and non-home discharges (P = 0.0003). The revision cohort did experience significantly increased odds of 30-day ED admission (P = 0.04) and had higher direct hospitalization (P = 0.03) and surgical (P < 0.0001) costs.

Conclusion: Complication rates, including incidental durotomy, were similar between primary and revision PCDF cohorts. Although prior surgery status did not predict complication risk, comorbidity burden did. Nevertheless, patients undergoing revision procedures had decreased risk of required ICU stay but greater risk of 30-day ED admission and higher direct hospitalization and surgical costs.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004019DOI Listing
October 2021

Nonsteroidal anti-inflammatory drug use and concussions in adolescent athletes: incidence, severity, and recovery.

J Neurosurg Pediatr 2021 Jul 30;28(4):476-482. Epub 2021 Jul 30.

1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and.

Objective: Given concerns about the potential long-term effects of concussion in young athletes, concussion prevention has become a major focus for amateur sports leagues. Athletes have been known to frequently use anti-inflammatory medications to manage injuries, expedite return to play, and treat concussion symptoms. However, the effects of baseline nonsteroidal anti-inflammatory drug (NSAID) use on the susceptibility to head injury and concussion remain unclear. This study aims to assess the effects of preinjury NSAID use on concussion incidence, severity, and recovery in young athletes.

Methods: Data from 25,815 ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing) tests were obtained through a research agreement with ImPACT Applications Inc. Subjects ranged in age from 12 to 22 years old. Those who reported NSAID use at baseline were assigned to one (anti-inflammatory [AI]) cohort, whereas all others were assigned to the control (CT) cohort. Differences in head trauma and concussion incidence, severity, and recovery were assessed using chi-square tests, unpaired t-tests, and Kaplan-Meier plots.

Results: The CT cohort comprised a higher percentage (p < 0.0001) of males (66.30%) than the AI cohort (44.16%) and had a significantly greater portion of athletes who played football (p = 0.004). However, no statistically significant differences were found between the two cohorts in terms of the incidence of head trauma (CT = 0.489, AI = 0.500, p = 0.9219), concussion incidence (CT = 0.175, AI = 0.169, p = 0.7201), injury severity, or median concussion recovery time (CT = 8, AI = 8, p = 0.6416). In a multivariable analysis controlling for baseline differences between the cohorts, no association was found between NSAID use and concussion incidence or severity.

Conclusions: In this analysis, the authors found no evidence that preinjury use of NSAIDs affects concussion risk in adolescent athletes. They also found no indication that preinjury NSAID use affects the severity of initial injury presentation or concussion recovery.
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http://dx.doi.org/10.3171/2021.2.PEDS2115DOI Listing
July 2021

Augmented Reality in Spine Surgery.

World Neurosurg 2021 07;151:290

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

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http://dx.doi.org/10.1016/j.wneu.2021.05.041DOI Listing
July 2021

Fluorescence-Guided Surgery: A Review on Timing and Use in Brain Tumor Surgery.

Front Neurol 2021 16;12:682151. Epub 2021 Jun 16.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

Fluorescence-guided surgery (FGS) allows surgeons to have improved visualization of tumor tissue in the operating room, enabling maximal safe resection of malignant brain tumors. Over the past two decades, multiple fluorescent agents have been studied for FGS, including 5-aminolevulinic acid (5-ALA), fluorescein sodium, and indocyanine green (ICG). Both non-targeted and targeted fluorescent agents are currently being used in clinical practice, as well as under investigation, for glioma visualization and resection. While the efficacy of intraoperative fluorescence in studied fluorophores has been well established in the literature, the effect of timing on fluorophore administration in glioma surgery has not been as well depicted. In the past year, recent studies of 5-ALA use have shown that intraoperative fluorescence may persist beyond the previously studied window used in prior multicenter trials. Additionally, the use of fluorophores for different brain tumor types is discussed in detail, including a discussion of choosing the right fluorophore based on tumor etiology. In the following review, the authors will describe the temporal nature of the various fluorophores used in glioma surgery, what remains uncertain in FGS, and provide a guide for using fluorescence as a surgical adjunct in brain tumor surgery.
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http://dx.doi.org/10.3389/fneur.2021.682151DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245059PMC
June 2021

Rescue therapy for vasospasm following aneurysmal subarachnoid hemorrhage: a propensity score-matched analysis with machine learning.

J Neurosurg 2022 Jan 2;136(1):134-147. Epub 2021 Jul 2.

23University of California San Francisco, Fresno Campus, University Neurosciences Institutes, Fresno, California.

Objective: Rescue therapies have been recommended for patients with angiographic vasospasm (aVSP) and delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). However, there is little evidence from randomized clinical trials that these therapies are safe and effective. The primary aim of this study was to apply game theory-based methods in explainable machine learning (ML) and propensity score matching to determine if rescue therapy was associated with better 3-month outcomes following post-SAH aVSP and DCI. The authors also sought to use these explainable ML methods to identify patient populations that were more likely to receive rescue therapy and factors associated with better outcomes after rescue therapy.

Methods: Data for patients with aVSP or DCI after SAH were obtained from 8 clinical trials and 1 observational study in the Subarachnoid Hemorrhage International Trialists repository. Gradient boosting ML models were constructed for each patient to predict the probability of receiving rescue therapy and the 3-month Glasgow Outcome Scale (GOS) score. Favorable outcome was defined as a 3-month GOS score of 4 or 5. Shapley Additive Explanation (SHAP) values were calculated for each patient-derived model to quantify feature importance and interaction effects. Variables with high SHAP importance in predicting rescue therapy administration were used in a propensity score-matched analysis of rescue therapy and 3-month GOS scores.

Results: The authors identified 1532 patients with aVSP or DCI. Predictive, explainable ML models revealed that aneurysm characteristics and neurological complications, but not admission neurological scores, carried the highest relative importance rankings in predicting whether rescue therapy was administered. Younger age and absence of cerebral ischemia/infarction were invariably linked to better rescue outcomes, whereas the other important predictors of outcome varied by rescue type (interventional or noninterventional). In a propensity score-matched analysis guided by SHAP-based variable selection, rescue therapy was associated with higher odds of 3-month GOS scores of 4-5 (OR 1.63, 95% CI 1.22-2.17).

Conclusions: Rescue therapy may increase the odds of good outcome in patients with aVSP or DCI after SAH. Given the strong association between cerebral ischemia/infarction and poor outcome, trials focusing on preventative or therapeutic interventions in these patients may be most able to demonstrate improvements in clinical outcomes. Insights developed from these models may be helpful for improving patient selection and trial design.
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http://dx.doi.org/10.3171/2020.12.JNS203778DOI Listing
January 2022

Surgical Evacuation of Intracerebral Hemorrhage: The Potential Importance of Timing.

Stroke 2021 10 30;52(10):3391-3398. Epub 2021 Jun 30.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York.

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http://dx.doi.org/10.1161/STROKEAHA.121.032238DOI Listing
October 2021

Academic Productivity of United States Neurosurgeons Trained Abroad.

World Neurosurg 2021 08 13;152:e567-e575. Epub 2021 Jun 13.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Previous research in neurosurgery has examined academic productivity for U.S. medical graduates and residents. However, associations between scholarly output and international medical education, residency training, and fellowship training are scarcely documented.

Methods: We identified 1671 U.S. academic neurosurgeons in 2020 using publicly available data along with their countries of medical school, residency, and fellowship training. Using Scopus, h-index, number of publications, and number of times publications were cited were compiled. Demographic, subspeciality, and academic productivity variables were compared between training locations using univariate analysis and multivariable linear regression.

Results: Of the current neurosurgery faculty workforce, 16% completed at least 1 component of their training abroad. Canada was the most represented international country in the cohort. Academic productivity for neurosurgeons with international medical school and/or international residency did not significantly differ from that of neurosurgeons trained in the United States. Neurosurgeons with ≥1 U.S. fellowships or ≥1 international fellowships did not have higher academic productivity than neurosurgeons without a fellowship. However, dual fellowship training in both domestic and international programs was associated with higher mean h-index (β = 6.00, 95% confidence interval 1.01 to 10.98, P = 0.02), higher citations (β = 2092.0, 95% confidence interval 460.1 to 3724.0, P = 0.01), and a trend toward higher publications (β = 36.82, 95% confidence interval -0.21 to 73.85, P = 0.051).

Conclusions: Neurosurgeon scholarly output was not significantly affected by international training in medical school or residency. Dual fellowship training in both a domestic and an international program was associated with higher academic productivity.
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http://dx.doi.org/10.1016/j.wneu.2021.06.026DOI Listing
August 2021

Making a match: trends in the application, interview, and ranking process for the neurological surgery residency programs.

J Neurosurg 2021 May 28:1-7. Epub 2021 May 28.

Objective: Neurosurgery is a highly competitive residency field with a match rate lower than that of other specialties. The aim of this study was to analyze trends associated with the residency match process from the applicants' and program directors' perspectives.

Methods: Between 2010 and 2020, the National Residency Matching Program (NRMP) Applicant and Program Director Surveys, the NRMP Charting Outcomes reports, and the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books were analyzed to identify the number of applicants interviewed and ranked in US programs, the applicants' ranking preferences, the program directors' preferential factors in offering interviews, and rank list order. Applicants were divided between US senior medical students and independent applicants. Each cohort was dichotomized for matched and unmatched applicants.

Results: Over the study period, 2935 applicants applied to neurosurgery residency, including 2135 US senior medical students and 800 independent applicants, with an overall match rate of 65%. Overall, matched applicants had a significantly higher number of publications (p < 0.05). Among US senior medical student applicants, the application-to-interview ratio more than doubled over the study period, yet the number of interview invitations received, interviews accepted, and programs ranked remained unchanged. In the US senior medical student cohort, the number of submitted applications, interview invitations, accepted interviews, and programs ranked did not significantly differ between matched and unmatched applicants. In both cohorts, applicants shifted ranking factors from a more academic focus in early years to more well-being in later years. Letters of recommendation and board scores were key factors for program directors while screening applicants for interviews and ranking.

Conclusions: Neurosurgery residency continues to be a highly competitive field in medicine, with match rates of 65%. Recently, applicants have placed greater importance on ranking programs that value residents' well-being, as opposed to strictly academic factors. A data-driven understanding of factors important to applicants and program directors during the match process has the potential to improve resident candidate recruitment and overall resident-program fit, thereby improving well-being during residency, reducing the attrition rate, and overall enhancing the diversity of the neurosurgery resident workforce.
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http://dx.doi.org/10.3171/2020.11.JNS203637DOI Listing
May 2021

The Impact of Non-Elective Admission on Cost of Care and Length of Stay in Anterior Cervical Discectomy and Fusion: A Propensity-Matched Analysis.

Spine (Phila Pa 1976) 2021 Nov;46(22):1535-1541

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY.

Study Design: Retrospective cohort study.

Objective: To evaluate the impact of admission status on patient outcomes and healthcare costs in anterior cervical discectomy and fusion (ACDF).

Summary Of Background Data: Undergoing ACDF non-electively has been associated with higher patient comorbidity burdens. However, the impact of non-elective status on the total cost of hospital stay has yet to be quantified.

Methods: Patients undergoing ACDF at a single institution were placed into elective or non-elective cohorts. Propensity score-matching analysis in a 5:1 ratio controlling for insurance type and comorbidities was used to minimize selection bias. Demographics were compared by univariate analysis. Cost of care, length of stay (LOS), and clinical outcomes were compared between groups using multivariable linear and logistic regression with elective patients as reference cohort. All analyses controlled for sex, preoperative diagnosis, elixhauser comorbidity index (ECI), age, length of surgery, number of segments fused, and insurance type.

Results: Of 708 patients in the final ACDF cohort, 590 underwent an elective procedure and 118 underwent a non-elective procedure. The non-elective group was significantly younger (53.7 vs. 49.5 yr; P = 0.0007). Cohorts had similar proportions of private versus public health insurance, although elective had higher rates of commercial insurance (39.22% vs. 15.25%; P < 0.0001) and non-elective had higher rates of managed care (32.77% vs. 56.78%; P < 0.0001). Operation duration was significantly longer in non-elective patients (158 vs. 177 minutes; P = 0.01). Adjusted analysis also demonstrated that admission status independently affected cost (+$6877, 95% confidence interval [CI]: $4906-$8848; P < 0.0001) and LOS (+4.9 days, 95% CI: 3.9-6.0; P < 0.0001) for the non-elective cohort. The non-elective cohort was significantly more likely to return to the operating room (OR: 3.39; 95% CI: 1.37-8.36, P = 0.0008) and experience non-home discharge (OR: 10.95; 95% CI: 5.00-24.02, P < 0.0001).

Conclusion: Patients undergoing ACDF non-electively had higher cost of care and longer LOS, as well as higher rates of postoperative adverse outcomes.Level of Evidence: 3.
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November 2021

Sport Contact Level Affects Post-Concussion Neurocognitive Performance in Young Athletes.

Arch Clin Neuropsychol 2022 Jan;37(1):19-29

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Objective: Contact level affects the incidence of sports-related concussion. However, the effects of contact level on injury severity and recovery are less clear and are the focus of this study.

Method: Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) for athletes aged 12-22 was performed at baseline (n = 10,907 for 7,058 athletes), after suspected concussion determined by physicians or athletic trainers (n = 5,062 for 4,419 athletes), and during follow-up visits (n = 3,264 for 2,098 athletes). Athletes played contact/collision (CC), limited contact (LC), and noncontact (NC) sports. Injury incidence, severity, and recovery were measured using raw and change from baseline neurocognitive test scores. Comparisons between groups used univariate analysis and multivariable regression controlling for demographic variables.

Results: Compared to CC athletes, LC and NC athletes showed decreased suspected concussion incidence. At initial post-injury testing, all neurocognitive test scores were similar between groups except changes from baseline for processing speed were improved for LC compared to CC athletes. Upon follow-up testing, raw neurocognitive scores were better for NC compared to the contact collision athletes in verbal memory, processing speed, total symptom score, migraine cluster, cognitive cluster, and neuropsychiatric cluster scores. For change from baseline scores, LC athletes exhibited better performance on verbal memory, processing speed, and reaction time but also showed higher neuropsychiatric scores than CC athletes.

Conclusion: Neurocognitive scores between contact levels were similar at the first post-injury test. However, follow up showed many improved scores and symptoms for limited and NC sports compared to CC sports, which may indicate faster recovery.
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January 2022

Hemorrhage Rates After Implantation and Explantation of Stereotactic Electroencephalography: Reevaluating Patients' Risk.

World Neurosurg 2021 07 2;151:e100-e108. Epub 2021 Apr 2.

Department of Neurosurgery, Mount Sinai Hospital System, New York, New York, USA. Electronic address:

Objective: Stereoelectroencephalography (sEEG), despite its established usefulness, has not been thoroughly evaluated for its adverse events profile. In this study, hemorrhage rates were evaluated both per patient and per lead placed not only in the immediate postoperative period, but also over the course of admission and after explantation when available.

Methods: This is a single-center retrospective study of pediatric and adult patients undergoing sEEG lead placement at a large urban hospital. All available postoperative imaging was reviewed for the presence of hemorrhage, including any imaging occurring throughout admission as well as within 1 month of lead explantation. Age and number of leads placed per procedure were compared using an unpaired t test assuming unequal variance.

Results: A total of 1855 leads were placed in 147 cases. The mean age was 30.4 ±15.0 and the male/female ratio was 47:53. 9 leads (0.49%) in 9 cases (6.12%) were involved with postimplantation hemorrhage occurring on postoperative day 0.44 on average. Postexplantation imaging was available for 45 cases. Seven leads (1.40%) in 7 cases (15.56%) were involved with postexplantation hemorrhage occurring on average on postoperative day 1.42. There was a significant difference in mean age between patients with postexplantation hemorrhage versus control (45.0 vs. 32.2; P = 0.0277). No cases of hemorrhage required surgical intervention and no patients had permanent neurologic deficit.

Conclusions: Hemorrhage after sEEG lead implantation and explantation may be more common than previously reported. Consistent postexplantation imaging may be of clinical benefit in detecting hemorrhage that precludes patients from immediate discharge, particularly in older patients.
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http://dx.doi.org/10.1016/j.wneu.2021.03.139DOI Listing
July 2021
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