Publications by authors named "Allan Levi"

145 Publications

Vertebral multiple myeloma with pathological fracture: the most common etiology for emergency spine surgery in patients with no cancer diagnosis on admission.

Neurosurg Focus 2021 May;50(5):E2

Objective: Vertebral compression fractures are common in multiple myeloma (MM). Modern treatment paradigms place emphasis on treatment with radiation, with surgery reserved for cases involving frank instability or severe neural compression. However, experience at the authors' institution has led them to suspect a more prominent role for surgical intervention in some settings. The authors undertook the present study to better understand the incidence of MM in undiagnosed patients who require urgent surgery for pathological vertebral fracture.

Methods: The authors reviewed a prospectively collected database of all patients who underwent surgery with the senior author at their main hospital between June 1, 1998, and June 30, 2020. Patients admitted from the emergency room or after transfer from another hospital who then underwent surgery for pathological fracture during the same admission were included in the final analysis. Patients scheduled for elective surgery and those with previous cancer diagnoses were excluded.

Results: Forty-three patients were identified as having undergone urgent surgical decompression and/or stabilization for pathological fracture. Histopathology confirmed diagnosis of MM in 22 (51%) patients, lung metastasis in 5 (12%) patients, and breast metastasis in 4 (9%) patients. Twelve (28%) patients were diagnosed with other types of metastatic carcinoma or undifferentiated disease. Sixteen of 29 (55%) men and 6 of 14 (42%) women were diagnosed with MM (p = 0.02). Seventeen of 34 (50%) patients who underwent surgery for neurological deficit, 5 of 6 (83%) patients who underwent surgery for spinal instability, and 0 (0%) patients who underwent surgery for pain with impending spinal cord injury were diagnosed with MM (p = 0.12).

Conclusions: A majority of patients presenting to the authors' hospital with no history of malignancy who required urgent surgery for pathological compression fracture were found to have MM or plasmacytoma. This disease process may affect a significant portion of patients requiring decompressive or stabilizing surgery for compression fracture in academic medical centers.
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http://dx.doi.org/10.3171/2021.2.FOCUS201038DOI Listing
May 2021

The Focused Neurosurgical Examination During Telehealth Visits: Guidelines During the COVID-19 Pandemic and Beyond.

Cureus 2021 Feb 23;13(2):e13503. Epub 2021 Feb 23.

Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA.

Objective:  To provide guidelines to healthcare workers for performing a focused neurological examination via telemedicine during the coronavirus disease-2019 (COVID-2019) pandemic.

Methods:  We reviewed our department's outpatient clinic visits after the implementation of a telemedicine protocol in response to the COVID-19 crisis. Crossover rates from telehealth to in-person visits were evaluated and guidelines for performing a telemedicine neurological exam were created based on the consensus of 16 neurosurgical attending providers over a four-month period.

Results:  From March 23, 2020 to July 20, 2020, some 2157 telehealth visits were performed in our department. Some 26 were converted to in-person visits by the provider request with the most cited reason for conversion being the need for a more detailed patient evaluation. Based on these experiences, we created a graphical tutorial to address the key components of the neurological exam with adaptations specific to the telehealth visit.

Conclusions:  In response to the global coronavirus pandemic, telemedicine has become an integral part of neurosurgeons' daily practice. Telemedicine failures remain low but primarily occur due to a need for more comprehensive evaluations. We provide guidelines for the neurosurgical exam during telehealth visits in an effort to assuage some of these issues.
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http://dx.doi.org/10.7759/cureus.13503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992292PMC
February 2021

Phase 1 Safety Trial of Autologous Human Schwann Cell Transplantation in Chronic Spinal Cord Injury.

J Neurotrauma 2021 May 3. Epub 2021 May 3.

The Miami Project to Cure Paralysis, Departments of University of Miami, Miami, Florida, USA.

A phase 1 open-label, non-randomized clinical trial was conducted to determine feasibility and safety of autologous human Schwann cell (ahSC) transplantation accompanied by rehabilitation in participants with chronic spinal cord injury (SCI). Magnetic resonance imaging (MRI) was used to screen eligible participants to estimate an individualized volume of cell suspension to be implanted. The trial incorporated standardized multi-modal rehabilitation before and after cell delivery. Participants underwent sural nerve harvest, and ahSCs were isolated and propagated in culture. The dose of culture-expanded ahSCs injected into the chronic spinal cord lesion of each individual followed a cavity-filling volume approach. Primary outcome measures for safety and trend-toward efficacy were assessed. Two participants with American Spinal Injury Association Impairment Scale (AIS) A and two participants with incomplete chronic SCI (AIS B, C) were each enrolled in cervical and thoracic SCI cohorts ( = 8 total). All participants completed the study per protocol, and no serious adverse events related to sural nerve harvest or ahSC transplantation were reported. Urinary tract infections and skin abrasions were the most common adverse events reported. One participant experienced a 4-point improvement in motor function, a 6-point improvement in sensory function, and a 1-level improvement in neurological level of injury. Follow-up MRI in the cervical (6 months) and thoracic (24 months) cohorts revealed a reduction in cyst volume after transplantation with reduced effect over time. This phase 1 trial demonstrated the feasibility and safety of ahSC transplantation combined with a multi-modal rehabilitation protocol for participants with chronic SCI.
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http://dx.doi.org/10.1089/neu.2020.7590DOI Listing
May 2021

Schwann cell delivery via a novel 3D collagen matrix conduit improves outcomes in critical length nerve gap repairs.

J Neurosurg 2021 Feb 19:1-11. Epub 2021 Feb 19.

1Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida; and.

Objective: The current clinical standard of harvesting a nerve autograft for repair of long-segment peripheral nerve injuries (PNIs) is associated with many potential complications. Guidance channels offer an alternative therapy. The authors investigate whether autologous Schwann cells (SCs) implanted within a novel collagen-glycosaminoglycan conduit will improve axonal regeneration in a long-segment PNI model.

Methods: Novel NeuraGen 3D collagen matrix conduits were implanted with autologous SCs to investigate axonal regeneration across a critical size defect (13 mm) in male Fischer rat sciatic nerve. Reversed sciatic nerve autografts served as positive controls, and conduits filled with serum only as negative controls. Electrophysiological assessments were made in vivo. Animals were killed at 4 or 16 weeks postinjury, muscle weights were measured, and grafts underwent immunohistochemical and morphometric analysis.

Results: SC survival was confirmed by the presence of green fluorescent protein-labeled SCs within regenerated fibers. Regeneration and elongation of myelinated axons in all segments of the graft were significantly enhanced at 16 weeks in the SC-filled conduits compared to the conduit alone and were statistically similar to those of the autograft. Nerves repaired with SC-filled conduits exhibited onset latencies and nerve conduction amplitudes similar to those of the contralateral controls and autograft (p < 0.05). Adding SCs to the conduit also significantly reduced muscle atrophy compared to conduit alone (p < 0.0001).

Conclusions: Repair of long-segment PNI of rat sciatic nerve is significantly enhanced by SC-filled NeuraGen 3D conduits. Improvements in the total number of myelinated axons, axon diameter, and myelin thickness throughout SC-filled conduits allow for significant recovery in nerve conduction and a decrease in muscle atrophy.
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http://dx.doi.org/10.3171/2020.8.JNS202349DOI Listing
February 2021

Neurophysiological Changes in the First Year After Cell Transplantation in Sub-acute Complete Paraplegia.

Front Neurol 2020 18;11:514181. Epub 2021 Jan 18.

The Miami Project to Cure Paralysis, Miller School of Medicine, The University of Miami, Miami, FL, United States.

Neurophysiological testing can provide quantitative information about motor, sensory, and autonomic system connectivity following spinal cord injury (SCI). The clinical examination may be insufficiently sensitive and specific to reveal evolving changes in neural circuits after severe injury. Neurophysiologic data may provide otherwise imperceptible circuit information that has rarely been acquired in biologics clinical trials in SCI. We reported a Phase 1 study of autologous purified Schwann cell suspension transplantation into the injury epicenter of participants with complete subacute thoracic SCI, observing no clinical improvements. Here, we report longitudinal electrophysiological assessments conducted during the trial. Six participants underwent neurophysiology screening pre-transplantation with three post-transplantation neurophysiological assessments, focused on the thoracoabdominal region and lower limbs, including MEPs, SSEPs, voluntarily triggered EMG, and changes in GSR. We found several notable signals not detectable by clinical exam. In all six participants, thoracoabdominal motor connectivity was detected below the clinically assigned neurological level defined by sensory preservation. Additionally, small voluntary activations of leg and foot muscles or positive lower extremity MEPs were detected in all participants. Voluntary EMG was most sensitive to detect leg motor function. The recorded MEP amplitudes and latencies indicated a more caudal thoracic level above which amplitude recovery over time was observed. In contrast, further below, amplitudes showed less improvement, and latencies were increased. Intercostal spasms observed with EMG may also indicate this thoracic "motor level." Galvanic skin testing revealed autonomic dysfunction in the hands above the injury levels. As an open-label study, we can establish no clear link between these observations and cell transplantation. This neurophysiological characterization may be of value to detect therapeutic effects in future controlled studies.
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http://dx.doi.org/10.3389/fneur.2020.514181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848788PMC
January 2021

Meralgia paresthetica treated by injection, decompression, and neurectomy: a systematic review and meta-analysis of pain and operative outcomes.

J Neurosurg 2021 Jan 15:1-11. Epub 2021 Jan 15.

1Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida; and.

Objective: Meralgia paresthetica is caused by entrapment of the lateral femoral cutaneous nerve (LFCN) and often presents with pain. Multiple treatment options targeting the LFCN can be pursued to treat the pain should conservative measures fail, with the most common options being injection, neurolysis, and neurectomy. However, their efficacy in causing pain relief and their clinical outcomes have yet to be directly compared. The aim of this study was to interrogate the contemporary literature and quantitatively define how these options compare.

Methods: The electronic databases Ovid Embase, PubMed, SCOPUS, and the Cochrane Library were interrogated from inception to May 2020 following the PRISMA guidelines. Candidate articles were screened against prespecified criteria. Outcome data were abstracted and pooled by random-effects meta-analysis of proportions.

Results: There were 25 articles that satisfied all criteria, reporting outcomes for a total of 670 meralgia paresthetica patients, with 78 (12%) treated by injection, 496 (74%) by neurolysis, and 96 (14%) by neurectomy. The incidence of complete pain relief was 85% (95% CI 71%-96%) after neurectomy, 63% (95% CI 56%-71%) after neurolysis, and 22% (95% CI 13%-33%) after injection, which were all statistically different (p < 0.01). The incidence of revision procedures was 12% (95% CI 4%-22%) after neurolysis and 0% (95% CI 0%-2%) after neurectomy, which were significantly lower than 81% (95% CI 64%-94%) after injection (p < 0.01). The incidences of treatment complications were statistically comparable across all three treatments, ranging from 0% to 5% (p = 0.34).

Conclusions: There are multiple treatment options to target pain in meralgia paresthetica. The incidence of complete pain relief appears to be the greatest among the 3 interventions after neurectomy, accompanied by the lowest incidence of revision procedures. These findings should help inform patient preference and expectations. Greater exploration of the anatomical rationale for incomplete pain relief after surgical intervention will assist in optimizing further surgical treatment for meralgia paresthetica.
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http://dx.doi.org/10.3171/2020.7.JNS202191DOI Listing
January 2021

Posterior Surgical Approach for Ventral Cervical Spinal Cord Herniation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Feb;20(3):E215-E216

Spinal cord herniation (SCH) is a rare condition that is typically of idiopathic origin. Although SCH is mostly found in the thoracic region because of a dural defect, there are some reports of cervical SCH following surgery or trauma.1-3 Spinal cord tethering can be a result of SCH or as a standalone issue.4,5 These conditions can lead to progressive neurological deficits, including numbness, gait disturbances, and decreased muscle strength, requiring surgical correction. There are limited reports of surgical procedures for ventral SCHs. Several reports exist using a ventral approach for intradural tumors, but it is not commonly employed because of the inability to obtain adequate dural closure.6 Much of the literature on SCH comes from idiopathic and congenital cases in the thoracic spine.7,8 Posterior and posterolateral approaches for a ventral thoracic SCH have been described, as well as an anterior approach for a ventral cervical SCH.9-12 In this video, we describe a posterior approach for a ventral cervical SCH. A 38-yr-old male presented with progressive cervical myelopathy 9 yr after a C2-C3 schwannoma resection requiring an anterior approach and corpectomy of C3 with partial corpectomies of C2 and C4. A preoperative magnetic resonance imaging showed a ventrally herniated spinal cord at the top of the C3 vertebral body and below the C4 vertebral body. Informed consent was obtained. The posterior surgical approach involved a C1-C5 laminectomy, sectioning the dentate ligament, ventral cord untethering, removal of residual tumor, and placement of a ventral sling. A significant improvement in sensory and motor function was observed postoperatively.
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http://dx.doi.org/10.1093/ons/opaa340DOI Listing
February 2021

Commentary: Genetic Events and Signaling Mechanisms Underlying Schwann Cell Fate in Development and Cancer.

Neurosurgery 2021 01;88(2):E128-E129

Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida.

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http://dx.doi.org/10.1093/neuros/nyaa501DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7803429PMC
January 2021

Differences Between Neurosurgical Subspecialties in Telehealth Adoption.

World Neurosurg 2021 02 16;146:e323-e327. Epub 2020 Nov 16.

Department of Neurological Surgery, University of Miami, Miami, Florida, USA. Electronic address:

Objective: The health care field has been faced with unprecedented challenges during the COVID 19 pandemic. One such challenge was the implementation of enhanced telehealth capabilities to ensure continuity of care. In this study, we aim to understand differences between subspecialties with regard to patient consent and satisfaction following telehealth implementation.

Methods: A retrospective review of the electronic medical record was performed from March 2 to May 8, 2020 to evaluate surgical consents before and after telehealth implementation. Press Ganey survey results were also obtained both pre- and posttelehealth implementation and compared.

Results: There was no significant difference in the percentage of new patients consented for surgery (after being seen via telehealth only) between the cranial and spine services. For procedures in which >10 patients were consented for surgery, the highest proportion of patients seen only via telehealth was for ventriculoperitoneal shunt placement/endoscopic third ventriculostomy for the cranial service, and lumbar laminectomy and microdiscectomy for the spine service. Additionally, the spine service experienced marked improvement in Press Ganey scores posttelehealth implementation with overall doctor ranking improving from the 29th to the 93rd percentile, and likelihood to recommend increasing from the 24th to the 94th percentile.

Conclusions: There were clear trends with regard to which pathologies and procedures were most amenable to telehealth visits, which suggests a potential roadmap for future clinic planning. Additionally, the notable improvement in spine patient satisfaction following the implementation of a telehealth program suggests the need for long-term process changes.
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http://dx.doi.org/10.1016/j.wneu.2020.10.080DOI Listing
February 2021

Comparison of adverse events between cervical disc arthroplasty and anterior cervical discectomy and fusion: a 10-year follow-up.

Spine J 2021 Feb 17;21(2):253-264. Epub 2020 Oct 17.

Department of Orthopedic Surgery, SUNY Upstate Medical University, 750 E. Adams St, Syracuse, NY 13210 USA. Electronic address:

Background Context: Cervical disc arthroplasty (CDA) has been advocated as an alternative to anterior cervical discectomy and fusion (ACDF) with the added potential to reduce the risk of adjacent level disc degeneration and segmental instability. However, the long-term adverse events of arthroplasty have yet to be fully reported.

Purpose: To investigate the 10-year follow-up adverse events rates between CDA and ACDF.

Study Design/setting: The study was a randomized, prospective, multicenter Investigational Device Exemption (IDE) trial and its continued follow-up as a postapproval study (PAS). Single level surgeries were performed for cervical disc pathologies between May 2002 and October 2004.

Patient Sample: n=463 patients.

Outcome Measures: Adverse events comparison of CDA and ACDF from self-reported and physiologic measures.

Methods: At each evaluation time point, subjects were queried for adverse events since their last visit; and all adverse events were documented, regardless of whether or not they appeared related to the surgery or device. Adverse events were recorded, categorized, and assessed for severity and relationship to the study device and/or surgical procedure. The 10-year cumulative rates for each type of adverse events were summarized using a life-table method for the time-to-event analysis. A log-rank test was used to compare the two treatment groups.

Results: A total of 242 patients received CDA and 221 patients received ACDF. At 10-year follow-up, 54% (130/242) of CDA patients and 47% (104/221) of the ACDF subjects were evaluated. At up to 10-year follow-up, 231 patients in the CDA group (cumulative rate 98.4%) and 199 patients in the ACDF group (cumulative rate 98.7%) had at least one adverse event. Overall, the difference in the cumulative rate of all adverse events over 10 years was not statistically different (p=0.166). The cumulative rates of the following adverse events were not different between the two groups for cancer, cardiovascular, death, dysphonia/dysphagia, gastrointestinal, infection, urogenital, respiratory, implant displacement/loosening, implant malposition, neck and arm pain, neurological, other pain, spinal events, and intraoperative vascular injury. However, there were more adverse events in the CDA group resulting from trauma (p=.012) and more spinal events at the index level (p=.006). The ACDF group had significantly more nonunion events (p=.019), and nonunion outcome pending (p=.034), adjacent level spinal events (p=.033), and events that fell into the "other" category (p=.015).

Conclusions: The cumulative rates of patients who had any adverse events were not different between the artificial cervical disc and the anterior cervical arthrodesis groups. In addition, the cumulative rates were not different between the two groups for the majority of categories as well.
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http://dx.doi.org/10.1016/j.spinee.2020.10.013DOI Listing
February 2021

Ultrasound-Guided Needle Localization Wires in Peripheral Nerve Injuries With Long Segmental Defects: Technical Case Report.

Oper Neurosurg (Hagerstown) 2020 Dec;20(1):E60-E65

The Miami Project to Cure Paralysis, Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.

Background And Importance: In cases of severe nerve trauma with significant local soft tissue damage, identification and subsequent repair of nerve stumps can pose a technical challenge. Ultrasound (US) localization in peripheral nerve surgery has recently become popular. We present a case report illustrating the use of needle-wire localization systems to identify proximal and several distal branches of an injured femoral nerve with a large segmental defect in order to illustrate how such techniques can be used to make surgical repair more efficient, particularly with identifying the distal stump(s).

Clinical Presentation: We illustrate a case of a 16-yr-old female involved in a traumatic accident that lead to a severe injury of the femoral nerve and artery. The patient presented with a 7.3-cm defect between the proximal and distal aspect of the femoral nerve and its branches, respectively. High-resolution US was used to identify the proximal, large femoral nerve, and 3 distal stumps. By enlisting our musculoskeletal radiology team, we were able to trace distal branches of the femoral nerve and see their target muscles. Three separate US flexible needles were used to locate small muscular branches of the femoral nerve and 1 to locate the proximal stump. Intraoperatively, the localization wires allowed for safe and efficient dissection of proximal and distal nerve stumps in a significantly scarred and edematous plane.

Conclusion: US-guided needle-wire localization has shown promise in identifying the distal stumps and minimizing tissue dissection. Preoperative US guidance significantly aided in nerve repair for this severe injury without increasing morbidity.
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http://dx.doi.org/10.1093/ons/opaa297DOI Listing
December 2020

Early Changes to Neurosurgery Resident Training During the COVID-19 Pandemic at a Large U.S. Academic Medical Center.

World Neurosurg 2020 12 28;144:e926-e933. Epub 2020 Sep 28.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: The coronavirus disease 2019 pandemic has led to sweeping changes in residency programs across the world, including cancellation of elective cases. The effects of safety measures on neurosurgical training remain unclear. To understand how neurosurgical residents have been affected, we analyzed the operative experience in the months leading up to and during the pandemic.

Methods: The resident and institutional case totals were tallied for a single residency program in Miami-Dade County from January 1, 2019 to June 30, 2020. A matched cohort analysis was performed before and during the pandemic to assess the effects on resident surgical training.

Results: The case totals for all levels of training were lower when restrictions were placed on elective surgeries. An average of 11 cases was logged in April 2020, a decrease from 26 cases in April 2019 (95% confidence interval, 8.7-22; P < 0.01). An average of 20 cases was logged in May 2020, a decrease from 25 cases in May 2019 (95% confidence interval, 1.2-8.8; P = 0.01). In April and May 2020, 299 (66%) and 148 (50%) fewer cases had been performed at our institution compared with April and May 2109.

Conclusions: Operative experience was reduced for residents during the months when the performance of elective cases was restricted. Our data suggest experience in some areas of neurosurgery were more affected than were others, and residents at different levels of training were also affected differently. However, the extent of the coronavirus disease 2019 pandemic on neurosurgical training is unlikely to be understood in the short term.
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http://dx.doi.org/10.1016/j.wneu.2020.09.125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521299PMC
December 2020

Telemedicine in Neurosurgery: Lessons Learned from a Systematic Review of the Literature for the COVID-19 Era and Beyond.

Neurosurgery 2020 12;88(1):E1-E12

University of Miami, Department of Neurosurgery, Miami, Florida.

Background: Evolving requirements for patient and physician safety and rapid regulatory changes have stimulated interest in neurosurgical telemedicine in the COVID-19 era.

Objective: To conduct a systematic literature review investigating treatment of neurosurgical patients via telemedicine, and to evaluate barriers and challenges. Additionally, we review recent regulatory changes that affect telemedicine in neurosurgery, and our institution's initial experience.

Methods: A systematic review was performed including all studies investigating success regarding treatment of neurosurgical patients via telemedicine. We reviewed our department's outpatient clinic billing records after telemedicine was implemented from 3/23/2020 to 4/6/2020 and reviewed modifier 95 inclusion to determine the number of face-to-face and telemedicine visits, as well as breakdown of weekly telemedicine clinic visits by subspecialty.

Results: A total of 52 studies (25 prospective and 27 retrospective) with 45 801 patients were analyzed. A total of 13 studies were conducted in the United States and 39 in foreign countries. Patient management was successful via telemedicine in 99.6% of cases. Telemedicine visits failed in 162 cases, 81.5% of which were due to technology failure, and 18.5% of which were due to patients requiring further face-to-face evaluation or treatment. A total of 16 studies compared telemedicine encounters to alternative patient encounter mediums; telemedicine was equivalent or superior in 15 studies. From 3/23/2020 to 4/6/2020, our department had 122 telemedicine visits (65.9%) and 63 face-to-face visits (34.1%). About 94.3% of telemedicine visits were billed using face-to-face procedural codes.

Conclusion: Neurosurgical telemedicine encounters appear promising in resource-scarce times, such as during global pandemics.
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http://dx.doi.org/10.1093/neuros/nyaa306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454774PMC
December 2020

Employment Status for the First Decade Following Randomization to Cervical Disc Arthroplasty Versus Fusion.

Spine (Phila Pa 1976) 2020 Oct;45(20):1411-1418

Department of Orthopedic Surgery, SUNY Upstate Medical University, Syracuse, NY.

Study Design: An analysis of employment status data up to 10 years following the Federal Drug Administration (FDA) Investigational Device Exemption (IDE) randomized trial and extension as post-approval study comparing BRYAN cervical disc (Medtronic, Minneapolis, MN) arthroplasty (CDA) versus single-level anterior cervical discectomy and fusion (ACDF) was performed.

Objective: Ten-year experience with the BRYAN disc arthroplasty trial provides opportunity to report patient employment data.

Summary Of Background Data: The long-term consequences of arthroplasty remain incomplete, including the occurrence of occupational compromise.

Methods: Patients' employment status were measured at regular intervals in both groups up to 10 years.

Results: The preoperative employment status proportion was comparable between investigational (BRYAN CDA) and control (ACDF) groups. In the investigational group, 49.2% returned to work at 6 weeks compared with 39.4% of the control group (P = 0.046). At 6 months and 2 years postoperatively, there was a similar likelihood of active employment in both groups. After 2 years at all time points, 10% drop-off seen in control group employment, but not in investigational group. At 10 years, 76.2% CDA patients were employed to 64.1% ACDF patients (P = 0.057). Preoperative variables influencing work status at 10 years following CDA included: preoperative work status, age, and SF-36 Mental Component Score (SF-36 MCS); whereas, no significant preoperative factor identified with ACDF. Time to return to work was influenced in both groups by preoperative work status; and in the ACDF group: reaching age 65 at 10-year visit, preoperative arm pain and NDI score had significant influences.

Conclusion: More patients returned to work at 6 weeks after CDA compared with ACDF, although there was no difference by 6 months. After 2 years, a nonsignificant trend toward higher employment rates in the arthroplasty group was evident, but this difference could not be validated due to the very high rate of loss of patients to the follow-up.

Level Of Evidence: 2.
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http://dx.doi.org/10.1097/BRS.0000000000003565DOI Listing
October 2020

Supraclavicular Resection of a Cervical Rib Causing Thoracic Outlet Syndrome: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 10;19(5):E520

Miami Project to Cure Paralysis, Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida.

Presence of a cervical rib results from overdevelopment of the seventh cervical vertebrae.1-3 The cervical rib along with scalene muscles can cause neurogenic thoracic outlet syndrome.4,5 Rib resection is typically done via anterior approach, using either supraclavicular or transaxillary route.6,7 We present an operative video detailing supraclavicular resection of a cervical rib causing neurogenic thoracic outlet syndrome with direct decompression of the lower trunk of the brachial plexus. The patient presented with severe symptoms including hand atrophy. We were able to directly visualize the rib and resect it, along with scalene musculature. We present 3-mo follow-up data noting clinical improvement in neuropathic symptoms.
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http://dx.doi.org/10.1093/ons/opaa139DOI Listing
October 2020

Commentary: A Porcine Model of Peripheral Nerve Injury Enabling Ultra-Long Regenerative Distances: Surgical Approach, Recovery Kinetics, and Clinical Relevance.

Neurosurgery 2020 09;87(4):E520-E521

Department of Neurological Surgery, University of Miami, Miami, Florida.

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http://dx.doi.org/10.1093/neuros/nyaa121DOI Listing
September 2020

Temperature Management in Neurological and Neurosurgical Intensive Care Unit.

Ther Hypothermia Temp Manag 2020 06 23;10(2):86-90. Epub 2020 Apr 23.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

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http://dx.doi.org/10.1089/ther.2020.29072.pjlDOI Listing
June 2020

Advances in 3D angiography for spinal vascular malformations.

J Clin Neurosci 2020 Feb 11;72:79-83. Epub 2020 Jan 11.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.

Spinal vascular malformations are difficult to diagnose lesions that can be associated with significant permanent morbidity. The angioarchitecture of spinal vascular anatomy and the associated pathologies have only recently been illuminated by the advent of spinal angiography. However, conventional spinal digital subtraction angiography is often limited by significant variability, overlapping vessels, as well as an inability to understand the precise location of the nidus or fistula in relation to the spinal cord and spine. In this study, we present 4 unique cases wherein 3-dimensional rotational angiography (3DRA) with dual volume acquisition was useful in defining the anatomy of spinal fistulas as well as planning treatment.
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http://dx.doi.org/10.1016/j.jocn.2020.01.013DOI Listing
February 2020

The Risk of Peripheral Nerve Tumor Biopsy in Suspected Benign Etiologies.

Neurosurgery 2020 03;86(3):E326-E332

Miami Project to Cure Paralysis, Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida.

Background: Peripheral nerve sheath tumors (PNSTs) are tumors with unique clinical and imaging features that present to a variety of physicians. These lesions are often referred for biopsy, which can put nerve fascicles at risk. Preoperative biopsy may cause distortion of normal anatomic planes, making definitive resection difficult.

Objective: To evaluate the neurological risks of preoperative biopsy in benign PNSTs.

Methods: Surgical cases collected retrospectively using a prospectively established database of PNSTs treated by a single surgeon between 1997 and 2019. Patients were dichotomized depending on preoperative biopsy. The effects of biopsy were assessed via history and physical examination both pre- and postdefinitive resection.

Results: A total of 151 cases were included. Only 23.2% (35) of patients underwent preoperative biopsy, but 42.9% of these experienced new or worsening neurological examination immediately following biopsy. After definitive resection, the rate of neurological deficit was significantly different between the 2 groups with 60% of biopsy patients and 19% of those patients not biopsied experiencing decline in examination (F = 25.72, P < .001). Odds ratio for any postoperative deficit for biopsy was 6.40 (CI [2.8, 14.55], P < .001). Univariate logistic regression of neurological deficit with patient age, sex, tumor type, and biopsy status showed that only biopsy was associated with the occurrence of any postoperative deficit.

Conclusion: Biopsy of benign PNSTs is associated with a high rate of neurological deficit both immediately following the procedure and after definitive resection. Careful selection is imperative prior to proceeding with biopsy of nerve sheath tumors exhibiting benign features given the unacceptably high rate of neurological decline.
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http://dx.doi.org/10.1093/neuros/nyz549DOI Listing
March 2020

Stimulated Raman histology for rapid and accurate intraoperative diagnosis of CNS tumors: prospective blinded study.

J Neurosurg 2019 Dec 6:1-7. Epub 2019 Dec 6.

Departments of1Neurological Surgery and.

Objective: In some centers where brain tumor surgery is performed, the opportunity for expert intraoperative neuropathology consultation is lacking. Consequently, surgeons may not have access to the highest quality diagnostic histological data to inform surgical decision-making. Stimulated Raman histology (SRH) is a novel technology that allows for rapid acquisition of diagnostic histological images at the bedside.

Methods: The authors performed a prospective blinded cohort study of 82 consecutive patients undergoing resection of CNS tumors to compare diagnostic time and accuracy of SRH simulation to the gold standard, i.e., frozen and permanent section diagnosis. Diagnostic accuracy was determined by concordance of SRH-simulated intraoperative pathology consultation with a blinded board-certified neuropathologist, with official frozen section and permanent section results.

Results: Overall, the mean time to diagnosis was 30.5 ± 13.2 minutes faster (p < 0.0001) for SRH simulation than for frozen section, with similar diagnostic correlation: 91.5% (κ = 0.834, p < 0.0001) between SRH simulation and permanent section, and 91.5% between frozen and permanent section (κ = 0.894, p < 0.0001).

Conclusions: SRH-simulated intraoperative pathology consultation was significantly faster and equally accurate as frozen section.
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http://dx.doi.org/10.3171/2019.9.JNS192075DOI Listing
December 2019

Establishing validity of the fundamentals of spinal surgery (FOSS) simulator as a teaching tool for orthopedic and neurosurgical trainees.

Spine J 2020 04 18;20(4):580-589. Epub 2019 Nov 18.

Departments of Orthopedic Surgery, Biomedical Engineering, and Anatomy and Neurobiology, Neuroscience Research Facility, University of California, Irvine, CA, USA. Electronic address:

Background Context: Pedicle screw placement is a demanding surgical skill as a spine surgeon can face challenges including variations in pedicle morphology and spinal deformities. Available CT simulators for spine pedicle placement can be very costly and hands-on cadaver courses are limited by specimen availability and are not readily accessible.

Purpose: To conduct validation of a simulated training device for essential spine surgery skills.

Design: Cross-sectional, empirical study of physician performance on a surgical simulator model.

Sample: Spine attending physicians and residents from four different academic institutions across the United States.

Outcome Measures: Performance metrics on two surgical simulator tasks.

Methods: After IRB approval, an inexpensive ($30) simulator was developed to test two main psychomotor tasks (1) creation of the pedicle screw path with a standard gearshift probe without cortical breaks and (2) the ability to palpate for the presence or absence of cortical breaches as well as determine the location of wall defects. Orthopedic and neurosurgery residents (N=72) as well as spine attending surgeons (N=26) participated from four different institutions. To test construct validity, performance metrics were compared between participants of different training status through one-way analysis of variance and linear regression analysis, with significance set at p<.05.

Results: Spine attending surgeons consistently scored higher than the residents, in the screw trajectory task with triangular base (p=.0027) and defect probing task (p=.0035). In defect probing, performance improved with linear trend by number of residency training years with approaching significance (p=.0721). In that task, independent of institutional affiliation, PGY-2 residents correctly identified an average of 1.25±0.43 fewer locations compared with attending physicians (p=.0049). More than 80% of the spine attendings reported they would use the simulator for training purposes.

Conclusions: This low-cost fundamentals of spine surgery simulator detected differences in performances between spine attending surgeons and surgical residents. Programs should consider implementing a simulator such as fundamentals of spine surgery to assess and develop pedicle screw placement ability outside of the operating room.
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http://dx.doi.org/10.1016/j.spinee.2019.11.008DOI Listing
April 2020

Use of Cervical Disk Arthroplasty to Treat Noncontiguous Cervical Disk Herniations.

World Neurosurg 2020 Jan 10;133:163-166. Epub 2019 Oct 10.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Lois Pope Life Center, Miami, Florida, USA.

Background: Cervical disk arthroplasty is now a widely accepted alternative to anterior cervical interbody fusion, which is known to reduce normal cervical motion and increase the incidence of adjacent segment disease. Although multiple studies report the use of cervical disk arthroplasty to treat multilevel cervical disease, this is the first report in the literature detailing the placement of multiple, noncontiguous artificial disks.

Case Description: We describe a 41-year-old male who presented with myelopathy and left upper extremity radiculopathy resulting from 2 cervical disk herniations separated by a normal intervening level. He underwent an anterior cervical diskectomy and placement of an artificial disk prosthesis at cervical (C) 4-5 and C6-7 while leaving C5-6 intact.

Conclusions: This approach serves to preserve cervical motion, spinal stability, and lordosis across all 3 levels, thus demonstrating that it is a viable alternative to a multilevel anterior cervical interbody fusion.
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http://dx.doi.org/10.1016/j.wneu.2019.10.019DOI Listing
January 2020

Proximal Adjacent Segment Disease Manifesting as Retroodontoid Pseudotumor After Fusion to C2.

World Neurosurg 2020 Jan 27;133:90-96. Epub 2019 Sep 27.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: Although adjacent segment disease (ASD) following anterior cervical fusion has been well described in the literature, there is relative paucity of data on this pathology after posterior cervical fusion. To our knowledge, there have been no reported cases of proximal ASD following posterior fusion to C2.

Case Description: We present 2 cases of proximal ASD presenting as retroodontoid pseudotumors following posterior fusion to C2, both in middle-aged females without history of rheumatologic disease. The first occurred in a patient with Klippel-Feil deformity 13 years after C2-6 posterior cervical fusion, the second in a patient 3 and a half years following revisional circumferential C2-T2 fusion. Both were successfully treated with proximal extension of laminectomy and fusion to the occiput, supplemented in the first patient by transdural decompression of retroodontoid mass.

Conclusions: Proximal ASD can manifest as retroodontoid pseudotumor at variable time intervals following posterior fusion to C2. Clinicians must account for this possibility in their decision making.
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http://dx.doi.org/10.1016/j.wneu.2019.09.113DOI Listing
January 2020

Reverse Bohlman technique for treatment of high-grade spondylolisthesis in an adult population.

J Clin Neurosci 2019 Nov 19;69:230-236. Epub 2019 Aug 19.

Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA. Electronic address:

Background/aims: Surgical techniques for treatment of high-grade spondylolisthesis (HGS) remain controversial. This study aims to evaluate both radiographic and clinical outcomes in patients with HGS treated with the "modified Bohlman" and Reverse Bohlman technique.

Methods: Review of consecutive HGS patients undergoing modified Bohlman and Reverse Bohlman at a single center from 2006 to 2018. Clinical, surgical, and radiographic data were collected.

Results: Six patients identified in the modified Bohlman treatment arm: and eight patients in the Reverse Bohlman group. Twelve (12) patients presented with high grade congenital spondylolisthesis at L5-S1; one patient presented with dissolution of the L5 vertebral body secondary to uncontrolled osteomyelitis that developed after a previous failed fusion; and one patient presented with iatrogenic L5-S1 spondylolisthesis after a previous L3-S1 fusion. One patient had medially placement pedicle screw and associated radiculopathy. All follow-up post = operative scans demonstrated solid fusion. Postoperatively, anterolisthesis improved from 18.3% to 10.1% (p = .0586) and the slip angle improved from 60.43° of kyphosis to 48.71° (p = .0139). No spondylolisthesis translational reduction maneuvers were attempted intraoperatively except for positioning on a sacral cushion to increase lordotic angle. Lumbar lordosis improved from 65.29 to 63.86 postoperatively. Four of our fourteen patients had long-term median follow-up of 28 months (range = 19-48 months) slip angle, percentage, and lumbar lordosis all improved from the patient's pre-operative measurements. The improvement in slip angle was nearly statistically significant with a p-value of 0.065.

Conclusions: Reverse Bohlman technique for high grade spondylolisthesis is a viable option when seeking to address adjacent level instability or slip.
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http://dx.doi.org/10.1016/j.jocn.2019.07.044DOI Listing
November 2019

Synovial Sarcoma of the Nerve-Clinical and Pathological Features: Case Series and Systematic Review.

Neurosurgery 2019 12;85(6):E975-E991

Miami Project to Cure Paralysis, Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida.

Background: Synovial sarcoma of the nerve is a rare entity with several cases and case series reported in the literature. Despite an improved understanding of the biology, the clinical course is difficult to predict.

Objective: To compile a series of patients with synovial sarcoma of the peripheral nerve (SSPN) and assess clinical and pathological factors and their contribution to survival and recurrence.

Methods: Cases from 2 institutions collected in patients undergoing surgical intervention for SSPN. Systematic review including PubMed and Scopus databases were searched for related articles published from 1970 to December 2018. Eligibility criteria: (1) case reports or case series reporting on SSPN, (2) clinical course and/or pathological features of the tumor reported, and (3) articles published in English.

Results: From patients treated at our institutions (13) the average follow-up period was 3.2 yr. Tumor recurrence was seen in 4 cases and death in 3. Systematic review of the literature yielded 44 additional cases with an average follow-up period of 3.6 yr. From pooled data, there were 10 recurrences and 7 deaths (20% and 14%, respectively). Adjuvant treatment used in 62.5% of cases. Immunohistochemical markers used in diagnosis varied widely; the most common are the following: Epithelial membrane antigen (EMA), cytokeratin, vimentin, cluster of differentiation (CD34), and transducin-like enhancer of split 1 (TLE1). Statistical analysis illustrated tumor size and use of chemotherapy to be negative predictors of survival. No other factors, clinically or from pathologist review, were correlated with recurrence or survival.

Conclusion: By combining cases from our institution with historical data and performing statistical analysis we show correlation between tumor size and death.
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http://dx.doi.org/10.1093/neuros/nyz321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6891799PMC
December 2019

Repair of isthmic pars interarticularis fractures: a literature review of conventional and minimally invasive techniques.

J Neurosurg Sci 2019 Jun;63(3):318-329

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA -

Introduction: The repair of symptomatic isthmic pars interarticularis fractures can result in excellent outcomes. A variety of operative interventions exist with conventional techniques requiring larger exposures. Recently described, less invasive techniques tend to minimize disruption of adjacent soft tissues, decrease postoperative pain, increase patient satisfaction, and improve return to work status and/or competitive sports. The present review details both conventional and minimally invasive techniques of pars interarticularis repairs. Also, the review uniquely describes the authors' technique of fluoroscopically guided direct pars screw placement with recombinant human morphogenic protein, with clinical and radiographic outcomes.

Evidence Acquisition: A PubMed database literature review and retrospective chart review were conducted, in search of patients with lumbar spondylosis treated surgically. Literature review focused on various surgical techniques in repairing pars interarticularis fractures. Retrospective chart review analyzed demographic, radiographic, as well as pre- and postoperative clinical outcomes data.

Evidence Synthesis: Surgical technique was characterized as traditional or minimally invasive operative technique. Four major operative techniques are discussed: The Buck repair, the Scott repair, the Morscher repair, and other pedicle-screw based repairs. The Levi technique is also described, utilizing minimally invasive techniques, in full.

Conclusions: Surgical treatment of isthmic pars interarticularis fractures is safe and effective. Many surgical techniques exist, however minimally invasive techniques tend to provide additional clinical benefit. Moreover, fluoroscopically guided direct pars screw placement with use of recombinant human morphogenic protein, may provide the most benefit, especially in adolescent patients with high levels of physical activity.
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http://dx.doi.org/10.23736/S0390-5616.19.04646-0DOI Listing
June 2019