Publications by authors named "Christoph Wipplinger"

45 Publications

Adenosine-induced transient circulatory arrest in transvenous embolization of cerebral arteriovenous malformations.

Neuroradiol J 2021 Mar 3:1971400921998972. Epub 2021 Mar 3.

Division of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran University of Medical Sciences, Iran.

Due to advances in interventional techniques, the transvenous approach may present an effective treatment option for embolization of brain arteriovenous malformations (AVMs). Contrary to the transarterial method, the transvenous approach can only be utilized in a specific subset of patients and is not suitable as a standard procedure for all AVM lesions. While this technique can be helpful in certain patients, careful patient selection to ensure patient safety and favorable clinical outcomes is important. However, especially in high-flow AVMs, targeted deposition of embolic materials through a transvenous access can be challenging. Therefore, a temporary flow arrest may prove helpful. Transient cardiac arrest by use of adenosine has been applied in cerebrovascular surgery but is not common for endovascular embolization. Adenosine-induced arrest and systemic hypotension may be a feasible, safe method to reduce flow and help endovascular transvenous embolization of certain AVMs. Our study evaluated the efficiency and safety of adenosine-induced circulatory arrest for transvenous embolization of cerebral AVMs.
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http://dx.doi.org/10.1177/1971400921998972DOI Listing
March 2021

Commentary: Machine Learning-Driven Metabolomic Evaluation of Cerebrospinal Fluid: Insights Into Poor Outcomes After Aneurysmal Subarachnoid Hemorrhage.

Neurosurgery 2021 Feb 13. Epub 2021 Feb 13.

Department of Neurosurgery, Geisinger Neuroscience Institute, Danville, Pennsylvania, USA.

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http://dx.doi.org/10.1093/neuros/nyab033DOI Listing
February 2021

Novel MIS 3D NAV Single Step Pedicle Screw System (SSPSS): Workflow, Accuracy and Initial Clinical Experience.

Global Spine J 2021 Jan 12:2192568220976393. Epub 2021 Jan 12.

Department of Neurological Surgery, Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York Presbyterian Hospital, NY, USA.

Study Design: Prospective case series.

Objective: SSPSS (single step pedicle screw system) was developed for minimally invasive spine surgery. We performed this study to report on safety, workflow, and our initial clinical experience with this novel technique.

Methods: The prospective study was conducted on patients who underwent pedicle screw fixation between October 2017 and April 2018 using a novel single step 3D navigated pedicle screw system for MIS. Outcome measurements were obtained from intraoperative computerized tomography. The images were evaluated to determine pedicle wall penetration. We used a grading system to assess the severity of the pedicle wall penetration. Breaches were classified as grade 1 (<2 mm), grade 2 (2-4 mm), or grade 3 (<4 mm), and as cranial, caudal, medial, and lateral.

Results: Our study includes 135 screws in 24 patients. SSPSS eliminated K-wires and multiple steps traditionally necessary for MIS pedicle screw insertion. The median time per screw was 2.45 minutes. 3 screws were corrected intraoperatively. Pedicle wall penetration occurred in 14 screws (10%). Grade 1 breaches occurred in 4 screws (3%) and grade 2 breaches occurred in 10 screws (7%). Lateral breaches were observed more often than medial breaches. The accuracy rate in our study was 90% (Grade 0 breach). No revision surgeries were needed and no complications occurred.

Conclusions: Our study suggests that SSPSS could be a safe, accurate, and efficient tool. Our accuracy rate is comparable to that found in the literature.
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http://dx.doi.org/10.1177/2192568220976393DOI Listing
January 2021

Imaging the local biochemical content of native and injured intervertebral disc using Fourier transform infrared microscopy.

JOR Spine 2020 Dec 14;3(4):e1121. Epub 2020 Sep 14.

Meinig School of Biomedical Engineering Cornell University Ithaca New York USA.

Alterations to the biochemical composition of the intervertebral disc (IVD) are hallmarks of aging and degeneration. Methods to assess biochemical content, such as histology, immunohistochemistry, and spectrophotometric assays, are limited in their ability to quantitatively analyze the spatial distribution of biochemical components. Fourier transform infrared (FTIR) microscopy is a biochemical analysis method that can yield both quantitative and high-resolution data about the spatial distribution of biochemical components. This technique has been largely unexplored for use with the IVD, and existing methods use complex analytical techniques that make results difficult to interpret. The objective of the present study is to describe an FTIR microscopy method that has been optimized for imaging the collagen and proteoglycan content of the IVD. The method was performed on intact and discectomized IVDs from the sheep lumbar spine after 6 weeks in vivo in order to validate FTIR microscopy in healthy and degenerated IVDs. FTIR microscopy quantified collagen and proteoglycan content across the entire IVD and showed local changes in biochemical content after discectomy that were not observed with traditional histological methods. Changes in collagen and proteoglycans content were found to have strong correlations with Pfirrmann grades of degeneration. This study demonstrates how FTIR microscopy is a valuable research tool that can be used to quantitatively assess the local biochemical composition of IVDs in development, degeneration, and repair.
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http://dx.doi.org/10.1002/jsp2.1121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7770196PMC
December 2020

Lateralization of inferior petrosal sinus sampling in Cushing's disease correlates with cavernous sinus venous drainage patterns, but not tumor lateralization.

Heliyon 2020 Oct 22;6(10):e05299. Epub 2020 Oct 22.

Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences (IUMS), Tehran, Iran.

Background: Inferior petrosal sinus sampling (IPSS) is known as the gold standard to distinguish whether excessive adrenocorticotropin hormone (ACTH) production origins from the pituitary gland or an ectopic source. However, due to a number of factors, the value of IPSS for adenoma lateralization may be limited. Aim of this study was to evaluate the influence of parasellar venous drainage (VD) patterns on IPSS findings in predicting lateralization of pituitary microadenomas.

Methods: We retrospectively reviewed records of confirmed cases of Cushing's disease which were evaluated by IPSS prior to endoscopic tansnasal trans-sphenoidal surgery (ETSS) to assess the ability of IPSS to predict adenoma laterality.

Results: Seventeen patients with pathologically confirmed Cushing's disease were retrospectively reviewed. The median age of the included patients was 37 years. Laterality of parasellar VD perfectly associated with lateralization as measured by IPSS. Symmetrical VD was associated with symmetrical ACTH gradient on IPSS. However, lateralization measured by IPSS did not show any significant correlation with lateralization detected during ETSS.

Conclusion: Our study suggests that IPSS lateralization results strongly depend on parasellar VD pattern but show no significant correlation with the adenoma lateralization found during ETSS. Thus, IPSS does not appear to be an appropriate modality to predict adenoma lateralization.
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http://dx.doi.org/10.1016/j.heliyon.2020.e05299DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586104PMC
October 2020

Surgical treatment and neurological outcome of infiltrating intramedullary astrocytoma WHO II-IV: a multicenter retrospective case series.

J Neurooncol 2021 Jan 22;151(2):181-191. Epub 2020 Oct 22.

Department of Neurosurgery, School of Medicine, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstr. 22, 81675, Munich, Germany.

Introduction: Primary malignant spinal astrocytomas present rare oncological entities with limited median survival and rapid neurological deterioration. Evidence on surgical therapy, adjuvant treatment, and neurological outcome is sparse. We aim to describe the treatment algorithm and clinical features on patients with infiltrating intramedullary astrocytomas graded WHO II-IV.

Methods: The following is a multicentered retrospective study of patients treated for spinal malignant glioma WHO II-IV in five high-volume neurosurgical departments from 2008 to 2019. Pilocytic astrocytomas were excluded. We assessed data on surgical technique, perioperative neurological status, adjuvant oncological therapy, and clinical outcome.

Results: 40 patients were included (diffuse astrocytoma WHO II n = 11, anaplastic astrocytoma WHO III n = 12, WHO IV n = 17). Only 40% were functionally independent before surgery, most patients presented with moderate disability (47.5%). Most patients underwent a biopsy (n = 18, 45%) or subtotal tumor resection (n = 15, 37.5%), and 49% of the patients deteriorated after surgery. Patients with WHO III and IV tumors were treated with combined radiochemotherapy. Median overall survival (OS) was 46.5 months in WHO II, 25.7 months in WHO III, and 7.4 months in WHO IV astrocytomas. Preoperative clinical status and WHO significantly influenced the OS, and the extent of resection did not.

Conclusion: Infiltrating intramedullary astrocytomas WHO II-IV present rare entities with dismal prognosis. Due to the high incidence of surgery-related neurological impairment, the aim of the surgical approach should be limited to obtaining the histological tissue via a biopsy or, tumor debulking in cases with rapidly progressive severe preoperative deficits.
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http://dx.doi.org/10.1007/s11060-020-03647-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875841PMC
January 2021

Gender-Specific Differences in Presentation and Management of Spinal Infection: A Single-Center Retrospective Study of 159 Cases.

Global Spine J 2020 Feb 20:2192568220905804. Epub 2020 Feb 20.

Medical University of Innsbruck, Innsbruck, Austria.

Study Design: A retrospective single-center analysis of 159 cases.

Objective: To investigate differences between male and female patients, as spinal infection (SI) represents a life-threatening condition and numerous factors may facilitate the course and outcome of SI, including patients' age and comorbidities, as well as gender. To date, no comparative data investigating sex differences in SI is available. Thus, the purpose of the present retrospective trial was to investigate differences between male and female patients.

Methods: A total of 159 patients who were treated for a spinal infection between 2010 and 2016 at our department were included in the analysis. The patients were categorized into 2 groups based on gender. Evaluation included magnetic resonance imaging, laboratory values, clinical outcome, and conservative/operative management.

Results: Male patients suffered from SI significantly more often than female patients (n = 101, 63.5% vs n = 58, 36.5%, = .001). However, female patients were initially affected more severely, as infection parameters were significantly higher ( = .032) and vertebral destruction was more serious ( = .018). Furthermore, women suffered from intraoperative complications more often ( = .024) and received erythrocyte concentrates more frequently ( = .01). Nevertheless, mortality rates and outcome were comparable. Pain scales were significantly higher in female patients at 12-month follow-up ( = .042).

Conclusion: Although male patients show a higher incidence for SI, the course of disease and the management is more challenging in female patients. Nevertheless, outcome after 12 months is comparably good. Underlying mechanisms may include a better immune response and dissimilar effects of antibiotic treatment in women. Pain management in female patients is still unsatisfactory after 12 months.
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http://dx.doi.org/10.1177/2192568220905804DOI Listing
February 2020

Endovascular reconstruction of iatrogenic internal carotid artery injury following endonasal surgery: a systematic review.

Neurosurg Rev 2020 Aug 29. Epub 2020 Aug 29.

Department of Neurosurgery, Babol University of Medical Sciences, Babol, Mazandaran, Iran.

The objective of this study is to provide an update on endovascular treatments for iatrogenic internal carotid artery (ICA) injuries following endonasal surgery. A systematic review of the literature was performed by using Medline, Cochrane library, and Scopus from 1999 to 2019. We used a combination of the MeSH terms "internal carotid artery," "iatrogenic disease," and "endovascular procedure." Twenty-six articles including 46 patients were identified for in this systematic review. The mean age of the patients was 49 years (CI: ± 4.2). The most common site of ICA injury was in cavernous segment (18 patients; 39%). The most common type of iatrogenic ICA injury was a traumatic pseudoaneurysm documented in 28 patients (60%). Endoluminal reconstruction was performed using covered stents in 28 patients, the Pipeline embolization device (PED) in 13 patients, the Surpass flow diverter device in three, the SILK flow diverter in one, and one case was treated using a combined approach of a covered stent and a PED. Flow diversion and covered stents resulted in a good clinical outcome in 94% and 89% of patients, respectively. This difference did not reach statistical significance (p = 1.0). Even though this systematic review was limited due to articles of small sample sizes and considerable heterogeneity, the results indicate that flow diverting devices and covered stents are good therapeutic options for endoluminal reconstruction of iatrogenic ICA injuries following endonasal surgery.
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http://dx.doi.org/10.1007/s10143-020-01379-zDOI Listing
August 2020

Early surgery may lower mortality in patients suffering from severe spinal infection.

Acta Neurochir (Wien) 2020 11 29;162(11):2887-2894. Epub 2020 Jul 29.

Department of Neurosurgery, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.

Purpose: Spinal infection (SI) is a life-threatening condition and treatment remains challenging. Numerous factors influence the outcome of SI and both conservative and operative care can be applied. As SI is associated with mortality rates between 2 and 20% even in developed countries, the purpose of the present study was to investigate the occurrence and causes of death in patients suffering from SI.

Methods: A retrospective analysis was performed on 197 patients, categorized into two groups according to their outcome: D (death) and S (survival). The diagnosis was based on clinical and imaging (MRI) findings. Data collected included demographics, clinical characteristics, comorbidities, infection parameters, treatment details, outcomes, and causes of death.

Results: The number of deaths was significantly higher in the conservative group (n = 9/51, 18%) compared with the operative counterpart (n = 8/146, 6%; p = 0.017). Death caused by septic multiorgan failure was the major cause of fatalities (n = 10/17, 59%) followed by death due to cardiopulmonary reasons (n = 4/17, 24%). The most frequent indication for conservative treatment in patients of group D included "highest perioperative risk" (n = 5/17, 29%).

Conclusion: We could demonstrate a significantly higher mortality rate in patients solely receiving conservative treatment. Mortality is associated with number and type of comorbidities, but also tends to be correlated with primarily acquired infection. As causes of death are predominantly associated with a septic patient state or progression of disease, our data may call for an earlier and more aggressive treatment. Nevertheless, prospective clinical trials will be mandatory to better understand the pathogenesis and course of spinal infection, and to develop high quality, evidence-based treatment recommendations.
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http://dx.doi.org/10.1007/s00701-020-04507-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7550317PMC
November 2020

Commentary: Women With First-Hand Tobacco Smoke Exposure Have a Higher Likelihood of Having an Unruptured Intracranial Aneurysm Than Nonsmokers: A Nested Case-Control Study.

Neurosurgery 2020 Jul 16. Epub 2020 Jul 16.

Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.

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http://dx.doi.org/10.1093/neuros/nyaa302DOI Listing
July 2020

Indirect Decompression Failure After Lateral Lumbar Interbody Fusion-Reported Failures and Predictive Factors: Systematic Review.

Global Spine J 2020 Apr 28;10(2 Suppl):8S-16S. Epub 2020 May 28.

New York-Presbyterian/Weill Cornell Medicine, New York, NY, USA.

Background: In patients with symptomatic lumbar stenosis undergoing lateral transpsoas approach for lumbar interbody fusion (LLIF) surgery, it is not always clear when indirect decompression is sufficient in order to achieve symptom resolution. Indirect decompression failure (IDF), defined as "postoperative persistent symptoms of nerve compression with or without a second direct decompression surgery to reach adequate symptom resolution," is not widely reported. This information, however, is critical to better understand the indications, the potential, and the limitations of indirect decompression.

Objective: The purpose of this study was to systematically review the current literature on IDF after LLIF.

Methods: A literature search was performed on PubMed. We included randomized controlled trials and prospective, retrospective, case-control studies, and case reports. Information on sample size, demographics, procedure, number and location of involved levels, follow-up time, and complications were extracted.

Results: After applying the exclusion criteria, we included 9 of the 268 screened articles that reported failure. A total of 632 patients were screened in these articles and detailed information was provided. Average follow-up time was 21 months. Overall reported incidence of IDF was 9%.

Conclusion: Failures of decompression via LLIF are inconsistently reported and the incidence is approximately 9%. IDF failure in LLIF may be underreported or misinterpreted as a complication. We propose to include the term "IDF" as described in this article to differentiate them from complications for future studies. A better understanding of why IDF occurs will allow surgeons to better plan surgical intervention and will avoid revision surgery.
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http://dx.doi.org/10.1177/2192568219876244DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263336PMC
April 2020

Tandem Microscopic Slalom Technique: The Use of 2 Microscopes Simultaneously Performing Unilateral Laminotomy for Bilateral Decompression in Multilevel Lumbar Spinal Stenosis.

Global Spine J 2020 Apr 28;10(2 Suppl):88S-93S. Epub 2020 May 28.

Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, New York, NY, USA.

Study Design: Technical note, retrospective case series.

Objective: Lumbar stenosis can be effectively treated using tubular unilateral laminotomy for bilateral decompression (ULBD). For multilevel stenosis, a multilevel ULBD through separate, alternating crossover approaches has been described as the "slalom technique." To increase efficacy, we introduced this approach with 2 microscopes simultaneously.

Methods: We collected data on 13 patients, with multilevel lumbar stenosis, operated at our institution between 2015 and 2016 by the aforementioned technique. We assessed surgical time (ST), estimated blood loss (EBL), complications, and revision surgeries. Furthermore, we provide a stepwise instruction for performing the tandem microscopic slalom technique in a safe and efficient manner.

Results: The mean age of the patients was 68 ± 8 years. The ST per level was 68 ± 19 minutes with an EBL per level of 39 ± 30 mL. We had no intraoperative complications and none of our patients required a revision surgery during a mean follow-up of 12 months.

Conclusions: We have shown that this technique is feasible and can be performed safely for multisegmental lumbar spinal stenosis with minimal tissue trauma and low EBL. Furthermore, randomized controlled studies with a larger sample size may be necessary to drive any final conclusions.
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http://dx.doi.org/10.1177/2192568219871918DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263332PMC
April 2020

Evolving Navigation, Robotics, and Augmented Reality in Minimally Invasive Spine Surgery.

Global Spine J 2020 Apr 28;10(2 Suppl):22S-33S. Epub 2020 May 28.

Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.

Innovative technology and techniques have revolutionized minimally invasive spine surgery (MIS) within the past decade. The introduction of navigation and image-guided surgery has greatly affected spinal surgery and will continue to make surgery safer and more efficient. Eventually, it is conceivable that fluoroscopy will be completely replaced with image guidance. These advancements, among others such as robotics and virtual and augmented reality technology, will continue to drive the value of 3-dimensional navigation in MIS. In this review, we cover pertinent features of navigation in MIS and explore their evolution over time. Moreover, we aim to discuss the key features germane to surgical advancement, including technique and technology development, accuracy, overall health care costs, operating room time efficiency, and radiation exposure.
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http://dx.doi.org/10.1177/2192568220907896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263339PMC
April 2020

Defining the MIS-TLIF: A Systematic Review of Techniques and Technologies Used by Surgeons Worldwide.

Global Spine J 2020 Apr 28;10(2 Suppl):151S-167S. Epub 2020 May 28.

Weill Cornell Brain and Spine Center, Weill Cornell Medicine, New York, NY, USA.

Study Design: Systematic review.

Objective: To date there is no consensus among surgeons as to what defines an MIS-TLIF (transforaminal lumbar interbody fusion using minimally invasive spine surgery) compared to an open or mini-open TLIF. This systematic review aimed to examine the MIS-TLIF techniques reported in the recent body of literature to help provide a definition of what constitutes the MIS-TLIF, based on the consensus of the majority of surgeons.

Methods: We created a database of articles published about MIS-TLIF between 2010 and 2018. We evaluated the technical components of the MIS-TLIF including instruments and incisions used as well the order in which key steps are performed.

Results: We could identify several patterns for MIS-TLIF performance that seemed agreed upon by the majority of MIS surgeons: use of paramedian incisions; use of a tubular retractor to perform a total facetectomy, decompression, and interbody cage implantation; and percutaneous insertion of the pedicle-screw rod constructs with intraoperative imaging.

Conclusion: Based on this review of the literature, the key features used by surgeons performing MIS TLIF include the use of nonexpandable or expandable tubular retractors, a paramedian or lateral incision, and the use of a microscope or endoscope for visualization. Approaches using expandable nontubular retractors, those that require extensive subperiosteal dissection from the midline laterally, or specular-based retractors with wide pedicle to pedicle exposure are far less likely to be promoted as an MIS-based approach. A definition is necessary to improve the communication among spine surgeons in research as well as patient education.
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http://dx.doi.org/10.1177/2192568219882346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263344PMC
April 2020

Successful endoluminal reconstruction of a pseudoaneurysm of the internal carotid artery following a transorbital stab injury.

Clin Neurol Neurosurg 2020 07 11;194:105838. Epub 2020 Apr 11.

Deptment of Neurosurgery, Tehran Medical Sciences Islamic Azad University, Tehran, Iran.

Traumatic penetrating injuries to the internal carotid artery (ICA) resulting in the formation of a traumatic pseudoaneurysm are potentially devastating injuries. Previously treatment included, open surgical occlusion of the affected vessel or endovascular embolization. However, with the advent of flow diverter stents, endoluminal reconstruction has become a viable treatment option. In this case report we describe the successful managment of an ICA pseudoaneurysm due to a transorbital stab injury. Endoluminal reconstruction in a traumatic aneurysm is a feasible option. Considering the risk of hemorrhagic complications due to dual antiplatelet therapy required after flow diverter placement, this treatment should only be chosen if insufficient collateral supply is found and occlusion of the affected vessel is not a viable option.
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http://dx.doi.org/10.1016/j.clineuro.2020.105838DOI Listing
July 2020

Commentary: George Chance and Frank Holdsworth: Understanding Spinal Instability and the Evolution of Modern Spine Injury Classification Systems.

Neurosurgery 2020 06;86(6):E519-E520

Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.

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http://dx.doi.org/10.1093/neuros/nyaa084DOI Listing
June 2020

Less Invasive Cervical Decompression via Unilateral Tubular Laminotomy Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Sep;19(4):E418

Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York.

This video demonstrates the step-by-step surgical technique for a less invasive cervical unilateral laminotomy for bilateral decompression (cervical ULBD). This technique allows surgeons to address bilateral cervical pathology while minimizing approach-related complications.1 In the video, we present the case of a 72-yr-old female patient with a past medical history of C3-C4 anterior cervical discectomy and fusion who presented in clinic with persistent posterior spinal cord compression and signal change. The patient had bilateral hand numbness, weakness, poor dexterity, and a positive Hoffman's sign. The patient was treated via a C3-C4 less invasive cervical ULBD using a mobile 3-dimensional (3D) C-arm (Ziehm Vision RFD 3D®, Nürnberg, Germany) combined with 3D computer navigation. Patient consent was obtained prior to performing the procedure. Contrary to anterior techniques, posterior cervical approaches avoid potential dysphasia, recurrent laryngeal nerve injury, and adjacent segment degeneration. Furthermore, the less invasive cervical ULBD results in decreased pain and postoperative narcotic usage, shorter hospital stays and fewer infections compared to open approaches, as well as a lower risk for postlaminectomy kyphosis and deformity, since it requires less muscle disruption and bony removal. Additionally, the use of total 3D navigation facilitates the workflow and minimizes radiation exposure.
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http://dx.doi.org/10.1093/ons/opaa059DOI Listing
September 2020

Combined nucleus pulposus augmentation and annulus fibrosus repair prevents acute intervertebral disc degeneration after discectomy.

Sci Transl Med 2020 03;12(534)

Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY 14853, USA.

Tissue-engineered approaches for the treatment of early-stage intervertebral disc degeneration have shown promise in preclinical studies. However, none of these therapies has been approved for clinical use, in part because each therapy targets only one aspect of the intervertebral disc's composite structure. At present, there is no reliable method to prevent intervertebral disc degeneration after herniation and subsequent discectomy. Here, we demonstrate the prevention of degeneration and maintenance of mechanical function in the ovine lumbar spine after discectomy by combining strategies for nucleus pulposus augmentation using hyaluronic acid injection and repair of the annulus fibrosus using a photocrosslinked collagen patch. This combined approach healed annulus fibrosus defects, restored nucleus pulposus hydration, and maintained native torsional and compressive stiffness up to 6 weeks after injury. These data demonstrate the necessity of a combined strategy for arresting intervertebral disc degeneration and support further translation of combinatorial interventions to treat herniations in the human spine.
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http://dx.doi.org/10.1126/scitranslmed.aay2380DOI Listing
March 2020

Review of the Highlights from the First Annual Global Neurosurgery 2019: A Practical Symposium.

World Neurosurg 2020 05 26;137:46-54. Epub 2020 Jan 26.

Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell, Medical College, New York Presbyterian Hospital, New York, New York, USA. Electronic address:

This paper provides a detailed report of Global Neurosurgery 2019: A Practical Symposium held January 18-19, 2019, at Weill Cornell Medical College, New York, New York, USA. The meeting convened an international faculty and audience, leaders in the world of global neurosurgery (GNS), and junior faculty and residents beginning their contribution to the field. Remote access for the symposium was provided to include faculty practicing in developing countries. The goal of the symposium was to present the state of the union of GNS initiatives worldwide, to use this forum as a means to centralize resources and converge parallel efforts, and to identify the largest areas of need and successful means of advancing training and care in these areas. The meeting also served as a conduit for the presentation of funding and training opportunities for junior faculty and trainees looking for avenues to gain support and mentorship in pursuing academic and clinical endeavors globally.
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http://dx.doi.org/10.1016/j.wneu.2020.01.140DOI Listing
May 2020

Commentary: Antiplatelet Therapy in Flow Diversion.

Neurosurgery 2020 02;86(2):E231-E233

Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.

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http://dx.doi.org/10.1093/neuros/nyz462DOI Listing
February 2020

Minimally Invasive Laminotomy for Contralateral "Over-the-Top" Foraminal Decompression Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Sep;19(3):E296

Department of Neurological Surgery, Weill Cornell Brain and Spine Center, New York-Presbyterian Hospital, Weill Cornell Medicine, New York, New York.

This video demonstrates the step-by-step surgical technique for the minimally invasive laminotomy for contralateral "over-the-top" foraminal decompression. This technique allows for excellent decompression with clearance of the contralateral recess and foramen. In the video, we present the case of a 51-yr-old female patient with a past medical history of left L5-S1 microdiscectomy who presented in clinic with residual/recurrent foraminal disc herniation at L5-S1 compressing the left L5 nerve root. The patient had left lower extremity pain in the left hip and thigh that radiated down the front and side of the leg, as well as tingling and numbness in the left foot. The patient was treated via a L5-S1 microdiscectomy using a portable intraoperative computed tomography scanner, (Airo®, Brainlab AG, Feldkirchen, Germany), combined with 3-dimensional (3D) computer navigation. Patient consent was obtained prior to performing the procedure. The main advantage of this technique is the direct "over-the-top" trajectory to the foraminal pathology that minimizes the need of facet joint resection. The use of 3D navigation facilitates surgical planning and further minimizes facet joint compromise. Particularly, the inferior facet contralateral to the approach side as well as its outer capsular surroundings can be preserved. Recent biomechanical studies have shown that "over-the-top" decompression produces significantly less instability than a traditional open midline laminectomy.
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http://dx.doi.org/10.1093/ons/opz399DOI Listing
September 2020

Flow Diverters Take an Ever Bigger Piece of the Aneurysm Treatment Pie: But How Do Individual Devices Compare?

World Neurosurg 2019 Dec 19;132:439-440. Epub 2019 Nov 19.

Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania, USA; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria.

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http://dx.doi.org/10.1016/j.wneu.2019.09.070DOI Listing
December 2019

Commentary: A Cohort Comparison Analysis of Fixed Pressure Ventriculoperitoneal Shunt Valves With Programmable Valves for Hydrocephalus Following Nontraumatic Subarachnoid Hemorrhage.

Oper Neurosurg (Hagerstown) 2020 04;18(4):E102-E103

Department of Neurosurgery and Neuroscience Institute, Geisinger, Danville, Pennsylvania.

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http://dx.doi.org/10.1093/ons/opz264DOI Listing
April 2020

Flow diverter embolization device for endovascular treatment of ruptured blister and wide necked very small aneurysms.

Heliyon 2019 Sep 13;5(9):e02241. Epub 2019 Sep 13.

Razi Hospital, Tehran University of Medical Sciences, Iran.

Purpose: Ruptured blood blisters (BBA) and very small, wide necked aneurysms (VSA) remain challenging lesions to treat due to their small size, wide necks, and thin, fragile walls. In the present study, we reviewed our experience with these aneurysms treated by flow diversion.

Methods: A total of 18 patients with hemorrhage due to a ruptured BBAs and VSAs, treated with flow diversion between July 2014 and March 2016 were included in this study. We analyzed clinical and radiographic outcomes.

Results: A total of 12 (66.7%) VSAs and 6 (33.3%) BBAs were treated with flow diversion. Fifteen (83.3%) and three (16.7%) aneurysms were located on the internal carotid artery and the basilar artery, respectively. On admission, a GCS score of 15 and WFNS grade 1 were found in 14 (77.7%) patients, 3 patients had an admission GCS of 13 and WFNS grade 2, one had an admission GCS of 8 and WFNS of 4. Fisher CT grades 2, 3, and 4 were observed in 11 (61.1%), 1 (5.6%), and 6 (33.3%) patients, respectively. Flow diversion was performed on average 5.6 days after onset of hemorrhage. 6 months post-intervention angiography showed complete obliteration of the aneurysms in all patients.

Conclusion: Our findings indicate that flow diversion in the acute and subacute phase of hemorrhage is a reliable treatment for reducing complications in patients with BBAs and VSAs. In patients with poor clinical presentation it might be reasonable to delay treatment until the first signs of recovery become apparent.
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http://dx.doi.org/10.1016/j.heliyon.2019.e02241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6819851PMC
September 2019

Combined Endovascular and Endoscopic Approach for Treatment of Concomitant Sphenoid Sinus Giant Traumatic Aneurysm and Direct Carotid Cavernous Fistulas.

World Neurosurg 2020 Feb 31;134:211-214. Epub 2019 Oct 31.

Divisions of Vascular and Endovascular Neurosurgery, Firoozgar Hospital, Iran, University of Medical Sciences, Tehran, Iran. Electronic address:

Background: Direct carotid cavernous fistulas (CCFs) and sphenoid sinus traumatic aneurysms are well-known pathologies that can present concomitantly in rare cases. Patients with both lesions are usually symptomatic from both the CCF and the traumatic aneurysm. Symptoms include proptosis, chemosis, bruit, epistaxis, visual field defects, and loss of vision. Surgical treatment can be challenging, and for most cases an endovascular approach is the treatment of choice.

Case Description: We present an unusual case of a direct CCF with an associated large traumatic aneurysm in the sphenoid sinus due to a history of trauma presenting with unusual symptoms that was treated by a combined endoscopic and endovascular approach.

Conclusions: Concurrent occurrence of a traumatic CCF and traumatic aneurysm of the cavernous segment is extremely rare. Early diagnosis and treatment of these lesions are important considering their high mortality rate. Complete occlusion of the fistula and aneurysm while preserving the patency of the carotid artery via an endovascular approach is the treatment of choice for these lesions.
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http://dx.doi.org/10.1016/j.wneu.2019.10.131DOI Listing
February 2020

Retrospective Review of Immediate Restoration of Lordosis in Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Comparison of Static and Expandable Interbody Cages.

Oper Neurosurg (Hagerstown) 2020 05;18(5):518-523

Hospital for Special Surgery, New York, New York.

Background: Sagittal alignment is an important consideration in spine surgery. The literature is conflicted regarding the effect of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) on sagittal parameters and the role of expandable cage technology.

Objective: To compare lordosis generated by static and expandable cages and to determine what factors affect postoperative sagittal parameters.

Methods: Preoperative regional lordosis (RL), segmental lordosis (SL), and posterior disc height (PDH) were compared to postoperative values in single-level MI-TLIF performed using expandable or static cages. Patients were stratified based on preoperative SL: low lordosis (<15 degrees), moderate lordosis (15-25 degrees), and high lordosis (>25 degrees). Regression analyses were conducted to determine factors associated with postoperative SL and PDH.

Results: Of the 171 patients included, 111 were in the static and 60 in the expandable cohorts. Patients with low preoperative lordosis experienced an increase in SL and maintained RL regardless of cage type. Those with moderate to high preoperative lordosis experienced a decrease in SL and RL with the static cage, but maintained SL and RL with the expandable cage. Although both cohorts showed an increase in PDH, the increase in the expandable cohort was greater. Preoperative SL was predictive of postoperative SL; preoperative SL, preoperative PDH, and cage type were predictive of postoperative PDH.

Conclusion: Expandable cages showed favorable results in restoring disc height and maintaining lordosis in the immediate postoperative period. Preoperative SL was the most significant predictor of postoperative SL. Thus, preoperative radiographic parameters and goals of surgery should be important considerations in surgical planning.
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http://dx.doi.org/10.1093/ons/opz240DOI Listing
May 2020

Proteoglycan removal by chondroitinase ABC improves injectable collagen gel adhesion to annulus fibrosus.

Acta Biomater 2019 10 16;97:428-436. Epub 2019 Aug 16.

Meinig School of Biomedical Engineering, Cornell University, Ithaca, NY, USA; Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, USA. Electronic address:

Intervertebral disc (IVD) herniations are currently treated with interventions that leave the IVD with persistent lesions prone to further herniations. Annulus fibrosus (AF) repair has become of interest as a method to seal defects in the IVD and prevent reherniation, but this requires strong adhesion of the implanted biomaterial to the native AF tissue. Our group has previously developed a high-density collagen (HDC) gel for AF repair and tested its efficacy in vivo, but its adhesion to the AF could be improved. Increased cell adhesion to cartilage has previously been reported through chondroitinase ABC (ChABC) digestion, which removes proteoglycans and increases access to cell binding motifs. Such approaches could also increase biomaterial adhesion to tissue, but the effects of ChABC digestion on AF have yet to be investigated. In this study, ovine AF tissue was digested with either 10 U/mL ChABC or saline for up to 10 min and the effect of this treatment on collagen adhesion between AF tissue samples was investigated by histology and mechanical testing in a lap-shear configuration. ChABC digestion removed proteoglycans within the AF in a time-dependent fashion and enhanced adhesion of the HDC gel to the AF. ChABC digestion increased the elastic toughness and total shear energy of the HDC gel-AF interface by 88% and 46% respectively. ChABC treatment enhanced the adhesion of the HDC gel to the AF without significantly decreasing native AF cell viability. Thus, ChABC digestion is a viable method to improve adhesion of biomaterials for AF repair. STATEMENT OF SIGNIFICANCE: Intervertebral disc herniations are currently treated with interventions that leave persistent lesions in the annulus fibrosus that are prone to further herniations. Annular repair is a promising method to seal lesions and prevent reherniation, but requires strong adhesion of the implanted biomaterial to native annulus fibrosus. Since large proteoglycans like aggrecan occupy regions of the extracellular matrix between collagen fibers in the annulus fibrosus, we hypothesized that removing proteoglycans via chondroitinase digestion would increase the adhesion of annular repair hydrogels. This investigation demonstrated that chondroitinase removed proteoglycans within annulus fibrosus tissue, enhanced the interaction of an injected collagen gel with the native tissue, and mechanically improved adhesion between the collagen gel and annulus fibrosus. This is the first study of its kind to evaluate the biochemical and mechanical effects of short-term chondroitinase digestion on annulus fibrosus tissue.
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http://dx.doi.org/10.1016/j.actbio.2019.08.024DOI Listing
October 2019

The impact of obesity and smoking on young individuals suffering from lumbar disc herniation: a retrospective analysis of 97 cases.

Neurosurg Rev 2020 Oct 14;43(5):1297-1303. Epub 2019 Aug 14.

Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria.

The negative impact on spinal diseases may apply not only to obesity but also to smoking. To investigate the influence of obesity and smoking on the development and recovery of lumbar disc herniation in young adults. Retrospective analysis of 97 patients who presented with lumbar disc herniation at the authors' department between 2010 and 2017. Data were collected using the patients' digital health records including demographics, clinical and neurological characteristics, treatment details, and outcomes. Ninety-seven patients between 17 and 25 years were included in this retrospective analysis. Patients were categorized into two groups according to their body mass index: obese (O, ≥ 30 kg/m) and non-obese (NO, < 30 kg/m). The proportion of obese patients in our cohort vs. in the overall population differed significantly (19.4% vs. 3.8-7.1%, RR 3.17; p < 0.01). Group NO showed a trend toward faster recovery of motor deficits (p = 0.067) and pain (p = 0.074). Also, the proportion of regular smokers differed significantly from the numbers of known smokers of the same age (62.4% vs. 30.2%, RR 2.0; p = 0.01). Obesity plus smoking showed a significantly negative impact on motor deficits postoperatively (p = 0.015) and at discharge (p = 0.025), as well as on pain values (p = 0.037) and on analgesic consumption (p = 0.034) at 6 weeks follow-up. The negative impact of obesity and smoking on the occurrence of lumbar disc herniation could be demonstrated for individuals aged 25 or younger. Furthermore, a trend to earlier recovery of motor deficits and significantly lower pain scales for non-obese and non-smoking patients could be shown.
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http://dx.doi.org/10.1007/s10143-019-01151-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7515935PMC
October 2020

MIS approaches in the cervical spine.

J Spine Surg 2019 Jun;5(Suppl 1):S74-S83

Weill Cornell Brain and Spine Center, Department of Neurological Surgery, Weill Cornell, Medical College, New York Presbyterian Hospital, New York, NY, USA.

Minimally invasive surgical approaches for the treatment of spinal pathologies have accelerated over the past three decades and resulted in superior functional outcomes with less complications. Yet cervical pathologies have been slower to gain traction for multiple anatomical factors and its "high-risk" profile. Various minimally invasive techniques for cervical disease have now been described and validated in long-term studies with comparable outcomes to traditional open approaches and concomitant reduction in morbidity and socioeconomic costs. Transnasal operations can be used to treat ventral upper cervical disease, circumventing traditional and morbid transoral approaches. Posterior-based focused treatments for radiculopathy and myelopathy such as tubular-guided foraminotomies and unilateral laminotomies for bilateral cord decompression have also been described and becoming increasingly less invasive. Cervical fusions can now be performed percutaneously through modified, stand-alone facet joint cages that can be packed with allogeneic bone graft. These advances have been facilitated by the development of intraoperative imaging technologies (intraoperative CT) and 3-dimensional stereotactic navigation software. While this review focuses on these procedures and evidence-based outcomes data, the future for MIS applications in cervical spine surgery will continue to evolve over the coming years with wider indications and technological adjuncts.
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http://dx.doi.org/10.21037/jss.2019.04.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6626755PMC
June 2019

Ten-Step Minimally Invasive Cervical Decompression via Unilateral Tubular Laminotomy: Technical Note and Early Clinical Experience.

Oper Neurosurg (Hagerstown) 2020 03;18(3):284-294

Weill Cornell Brain and Spine Center, Department of Neurological Surgery, New York-Presbyterian/Weill Cornell Medicine, New York, New York.

Background: Minimally invasive techniques utilizing tubular retractors have become an increasingly popular approach to the spinal column. The concept of a unilateral laminotomy for bilateral decompression (ULBD), first applied in the lumbar spine, has recently been applied to the cervical spine for the treatment of cervical spondylotic myelopathy (CSM). A better understanding of the indications and surgical techniques is required to effectively educate surgeons on how to appropriately and safely perform tubular cervical laminotomy via ULBD.

Objective: To describe a 10-step technique for minimally invasive cervical laminotomy and report our early clinical experience.

Methods: A retrospective review identified 15 patients with CSM who were treated with this procedure. Visual analogue scale (VAS), neck disability index (NDI), and modified Japanese Orthopaedic Association (mJOA) scores were obtained pre- and postoperatively.

Results: The mean age of the 15 patients was 73.1 ± 6.8 yr. The median number of levels treated was 1 (range 1-3). Mean operative time was 125.3 ± 30.8 or 81.7 ± 19.2 min per level. Mean estimated blood loss was 57.3 ± 24.6 cc. Median postoperative hospital length of stay was 36 h. No complications were encountered. Median follow-up was 18 mo. Mean pre- and postoperative VAS were 6.4 ± 2.4 and 1.0 ± 0.8, respectively (P < .001). Mean pre- and postoperative NDI were 46.4 ± 19.2 and 7.0 ± 6.9, respectively (P < .001). Mean pre- and postoperative Mjoa were 11.3 ± 2.5 and 14.5 ± 0.5, respectively (P < .001).

Conclusion: In our early clinical experience, minimally invasive cervical ULBD is safe and effective. Adherence to the presented 10-step technique will allow surgeons to safely address bilateral cervical pathology while avoiding complications.
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http://dx.doi.org/10.1093/ons/opz156DOI Listing
March 2020