Publications by authors named "Gabriel A Smith"

24 Publications

  • Page 1 of 1

Facial Sensory Restoration After Trigeminal Sensory Rhizotomy by Collateral Sprouting From the Occipital Nerves.

Neurosurgery 2020 05;86(5):E436-E441

School of Medicine, Case Western Reserve University, Cleveland, Ohio.

Background And Importance: Lesioning procedures are effective for trigeminal neuralgia (TN), but late pain recurrence associated with sensory recovery is common. We report a case of recurrence of type 1A TN and recovery of facial sensory function after trigeminal rhizotomy associated with collateral sprouting from upper cervical spinal nerves.

Clinical Presentation: A 41-yr-old woman presented 2 yr after open left trigeminal sensory rhizotomy for TN with pain-free anesthesia in the entire left trigeminal nerve distribution. Over 18 mo, she developed gradual recovery of facial sensation migrating anteromedially from the occipital region, eventually extending to the midpupillary line across the distribution of all trigeminal nerve branches. She reported recurrence of her triggered lancinating TN pain isolated to the area of recovered sensation with no pain in anesthetic areas. Nerve ultrasound demonstrated enlargement of ipsilateral greater and lesser occipital nerves, and occipital nerve block restored facial anesthesia and resolved her pain, indicating that recovered facial sensation was provided exclusively by the upper cervical spinal nerves. She underwent C2/C3 ganglionectomy, and ganglia were observed to be hypertrophic. Postoperatively, trigeminal anesthesia was restored with complete resolution of pain that persisted at 12-mo follow-up.

Conclusion: This is the first documented case of a spinal nerve innervating a cranial dermatome by collateral sprouting after cranial nerve injury. The fact that typical TN pain can occur even when sensation is mediated by spinal nerves suggests that the disorder can be centrally mediated and late failure after lesioning procedures may result from maladaptive reinnervation.
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May 2020

Impact of length of stay on HCAHPS scores following lumbar spine surgery.

J Neurosurg Spine 2019 May;31(3):366-371

1Center for Spine Health, Cleveland Clinic Foundation; and.

Objective: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys, completed by patients following an inpatient stay, are utilized to assess patient satisfaction and quality of the patient experience. HCAHPS results directly impact hospital and provider reimbursements. While recent work has demonstrated that pre- and postoperative factors can affect HCAHPS results following lumbar spine surgery, little is known about how these results are influenced by hospital length of stay (LOS). Here, the authors examined HCAHPS results in patients with LOSs greater or less than expected following lumbar spine surgery to determine whether LOS influences survey scores after these procedures.

Methods: The authors conducted a retrospective review of HCAHPS surveys, patient demographics, and outcomes following lumbar spine surgery at a single institution. A total of 391 patients who had undergone lumbar spine surgery and had completed an HCAHPS survey in the period between 2013 and 2015 were included in this analysis. Patients were divided into those with a hospital LOS equal to or less than the expected (LTE-LOS) and those with a hospital LOS longer than expected (GTE-LOS). Expected LOS was based on the University HealthSystem Consortium benchmarks. Nineteen questions from the HCAHPS survey were examined in relation to patient LOS. The primary outcome measure was a comparison of "top-box" ("9-10" or "always or usually") versus "low-box" ("1-8" and "somewhat or never") scores on the HCAHPS questions. Secondary outcomes of interest were whether the comorbid conditions of cancer, chronic renal failure, diabetes, coronary artery disease, hypertension, stroke, or depression occurred differently with respect to LOS. Statistical analysis was performed using Fisher's exact test for the 2 × 2 contingency tables and the chi-square test for categorical variables.

Results: Two hundred fifty-seven patients had an LTE-LOS, whereas 134 patients had a GTE-LOS. The only statistically significant difference in preoperative characteristics between the patient groups was hypertension, which correlated to a shorter LOS. A GTE-LOS was associated with a decreased likelihood of a top-box score for the HCAHPS survey items on doctor listening and pain control.

Conclusions: Here, the authors report a decreased likelihood of top-box responses for some HCAHPS questions following lumbar spine surgery if LOS is prolonged. This study highlights the need to further examine the factors impacting LOS, identify patients at risk for long hospital stays, and improve mechanisms to increase the quality and efficiency of care delivered to this patient population.
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May 2019

Self-referrals versus physician referrals: What new patient visit yields an actual surgical case?

J Neurosurg Spine 2018 Sep 15;29(3):314-321. Epub 2018 Jun 15.

2Center for Spine Health, Cleveland Clinic; and.

OBJECTIVE Spine surgeons in the United States continue to be overwhelmed by an aging population, and patients are waiting weeks to months for appointments. With a finite number of clinic visits per surgeon, analysis of referral sources needs to be explored. In this study, the authors evaluated patient referrals and their yield for surgical volume at a tertiary care center. METHODS This is a retrospective study of new patient visits by the spine surgery group at the Cleveland Clinic Center for Spine Health from 2011 to 2016. Data on all new or consultation visits for 5 identified spinal surgeons at the Center for Spine Health were collected. Patients with an identifiable referral source and who were at least 18 years of age at initial visit were included in this study. Univariate analysis was used to identify demographic differences among referral groups, and then multivariate analysis was used to evaluate those referral groups as significant predictors of surgical yield. RESULTS After adjusting for demographic differences across all referrals, multivariate analysis identified physician referrals as more likely (OR 1.48, 95% CI 1.04-2.10, p = 0.0293) to yield a surgical case than self-referrals. General practitioner referrals (OR 0.5616, 95% CI 0.3809-0.8278, p = 0.0036) were identified as less likely to yield surgical cases than referrals from interventionalists (OR 1.5296, p = 0.058) or neurologists (OR 1.7498, 95% CI 1.0057-3.0446, p = 0.0477). Additionally, 2 demographic factors, including distance from home and age, were identified as predictors of surgery. Local patients (OR 1.21, 95% CI 1.13-1.29, p = 0.018) and those 65 years of age or older (OR 0.80, 95% CI 0.72-0.87, p = 0.0023) were both more likely to need surgery after establishing care with a spine surgeon. CONCLUSIONS In conclusion, referrals from general practitioners and self-referrals are important areas where focused triaging may be necessary. Further research into midlevel providers and nonsurgical spine provider's role in these referrals for spine pathology is needed. Patients from outside of the state or younger than 65 years could benefit from pre-visit screening as well to optimize a surgeon's clinic time use and streamline patient care.
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September 2018

National Trends in Demographics and Outcomes Following Cervical Fusion for Cervical Spondylotic Myelopathy.

Global Spine J 2018 May 22;8(3):244-253. Epub 2017 Sep 22.

Cleveland Clinic, Cleveland, OH, USA.

Study Design: Retrospective trends analysis.

Objectives: Cervical fusion is a common adjunctive surgical modality used in the treatment of cervical spondylotic myelopathy (CSM). The purpose of this study was to quantify national trends in patient demographics, hospital characteristics, and outcomes in the surgical management of CSM.

Methods: This was a retrospective study that used the National Inpatient Sample. The sample included all patients over 18 years of age with a diagnosis of CSM who underwent cervical fusion from 2003 to 2013. The outcome measures were in-hospital mortality, length of stay, and hospital charges. Chi-square tests were performed to compare categorical variables. Independent tests were performed to compare continuous variables.

Results: We identified 62 970 patients with CSM who underwent cervical fusion from 2003 to 2013. The number of fusions performed per year in the treatment of CSM increased from 3879 to 8181. The average age of all fusion patients increased from 58.2 to 60.6 years ( < .001). Length of stay did not change significantly from a mean of 3.7 days. In-hospital mortality decreased from 0.6% to 0.3% ( < .01). Hospital charges increased from $49 445 to $92 040 ( < .001).

Conclusions: This study showed a dramatic increase in cervical fusions to treat CSM from 2003 to 2013 concomitant with increasing age of the patient population. Despite increases in average age and number of comorbidities, length of stay remained constant and a decrease in mortality was seen across the study period. However, hospital charges increased dramatically.
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May 2018

Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience.

Oper Neurosurg (Hagerstown) 2017 04;13(2):271-279

Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio.

Background: Neurosurgical complications from epidural injections have rarely been reported.

Objective: To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention.

Methods: A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed.

Results: Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1).

Conclusion: A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
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April 2017

Emergency department visits after lumbar spine surgery are associated with lower Hospital Consumer Assessment of Healthcare Providers and Systems scores.

Spine J 2018 Feb 21;18(2):226-233. Epub 2017 Jul 21.

Cleveland Clinic Center for Spine Health, 9500 Euclid Avenue, S-40 Cleveland, Ohio 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Avenue, S-40 Cleveland, Ohio 44195, USA.

Background: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys are used to assess the quality of the patient experience following an inpatient stay. Hospital Consumer Assessment of Healthcare Providers and Systems scores are used to determine reimbursement for hospital systems and incentivize spine surgeons nationwide. There are conflicting data detailing whether early readmission or other postdischarge complications are associated with patient responses on the HCAHPS survey. Currently, the association between postdischarge emergency department (ED) visits and HCAHPS scores following lumbar spine surgery is unknown.

Purpose: To determine whether ED visits within 30 days of discharge are associated with HCAHPS scores for patients who underwent lumbar spine surgery.

Study Design: Retrospective cohort study.

Patient Sample: A total of 453 patients who underwent lumbar spine surgery who completed the HCAHPS survey between 2013 and 2015 at a single tertiary care center.

Outcome Measures: The HCAHPS survey-the Centers for Medicare and Medicaid Services' official measure of patient experience-results for each patient were analyzed as the primary outcome of this study.

Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy or scoliosis. Patients who had an ED visit at our institution within 30 days of discharge were included in the ED visit cohort. The primary outcomes of this study include 21 measures of patient experience on the HCAHPS survey. Statistical analysis included Pearson chi-square for categorical variables, Student t test for normally distributed continuous variables, and Mann-Whitney U test for nonparametric variables. Additionally, log-binomial regression models were used to analyze the association between ED visits within 30 days after discharge and odds of top-box HCAHPS scores. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.

Results: After adjusting for patient-level covariates using log-binomial regression models, we found postdischarge ED visits were independently associated with lower likelihood of top-box score for several individual questions on HCAHPS. Emergency department visits within 30 days of discharge were negatively associated with perceiving your doctor as "always" treating you with courtesy and respect (risk ratio [RR] 0.26, p<.001), as well as perceiving your doctor as "always" listeningcarefully to you (RR 0.40, p=.003). Also, patients with an ED visit were less likely to feel as if their preferences were taken into account when leaving the hospital (RR 0.61, p=.008), less likely to recommend the hospital to family or friends (RR 0.46, p=.020), and less likely to rate the hospital as a 9 or a 10 out of 10, the top-box score (RR 0.43, p=.005).

Conclusions: Our results demonstrate a strong association between postdischarge ED visits and low HCAHPS scores for doctor communication, discharge information, and global measures of hospital satisfaction in a lumbar spine surgery population.
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February 2018

The association between the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey and real-world clinical outcomes in lumbar spine surgery.

Spine J 2017 11 8;17(11):1586-1593. Epub 2017 May 8.

Center for Spine Health, Cleveland Clinic, 9500 Euclid Avenue, S-40, Cleveland, OH 44195, USA; Department of Neurosurgery, Cleveland Clinic, 9500 Euclid Avenue, S-40, Cleveland, OH, USA.

Background Context: The patient experience of care as measured by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is currently used to determine hospital reimbursement. The current literature inconsistently demonstrates an association between patient satisfaction and surgical outcomes.

Purpose: To determine whether patient satisfaction with hospital experience is associated with better clinical outcomes in lumbar spine surgery.

Study Design: A retrospective cohort study conducted at a single institution.

Patient Sample: A total of 249 patients who underwent lumbar spine surgery between 2013 and 2015 and completed the HCAHPS survey.

Outcome Measures: Self-reported health status measures, including the EuroQol 5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and visual analog score for back pain (VAS-BP).

Methods: All patients undergoing lumbar spine surgery between 2013 and 2015 who completed an HCAHPS survey were studied. Patients were excluded from the study if they had been diagnosed with spinal malignancy, scoliosis, or had less than 1 year of follow-up. Patients who selected a 9 or 10 overall hospital rating (OHR) on HCAHPS were placed in the satisfied group, and the remaining patients comprised the unsatisfied group. The primary outcomes of this study include patient-reported health status measures such as EQ-5D, PDQ, and VAS-BP. No funds were received in support of this study, and the authors report no conflict of interest-associated biases.

Results: Our study population consisted of 249 patients undergoing lumbar spine surgery. Of these, 197 (79%) patients selected an OHR of 9 or 10 on the HCAHPS survey and were included in the satisfied group. The only preoperative characteristics that differed significantly between the twogroups were gender, a diagnosis of degenerative disc disease (DDD), heavy preoperative narcotic use, and a diagnosis of chronic renal failure. At 1 year follow-up, no statistically significant differences in EQ-5D, PDQ, or VAS-BP were observed. After using multivariable linear regression models to assess the association between patient satisfaction and pre- to 1-year postoperative changes in health status measures, selecting a top-box OHR was not found to be significantly associated with change in either EQ-5D (beta=0.055 [95% confidence interval {CI}: -0.035 to 0.145]), PDQ (beta=-9.013 [95% CI: -23.782 to 5.755]), or VAS-BP (beta=-0.849 [95% CI: -2.125 to 0.426]). These results suggest high satisfaction with the hospital experience may not necessarily correlate with favorable clinical outcomes.

Conclusions: Top-box OHR was not associated with pre- to 1-year postoperative improvement in EQ-5D, PDQ, and VAS-BP. Although the associations between high satisfaction and improvement in health status did not reach statistical significance, the best estimates from our multivariable models reflect greater clinical improvement with top-box satisfaction. Future studies should seek to investigate whether HCAHPS are a reliable indicator of quality care in lumbar spine surgery.
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November 2017

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases.

Global Spine J 2017 Apr 1;7(1 Suppl):64S-70S. Epub 2017 Apr 1.

Boston Medical Center, Scituate, MA, USA.

Study Design: A multicenter, retrospective review of C5 palsy after cervical spine surgery.

Objective: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery.

Methods: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. values were calculated using 2-sample test for continuous variables and χ tests or Fisher exact tests for categorical variables.

Results: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%).

Conclusion: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date.
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April 2017

A Multicenter Study of the Presentation, Treatment, and Outcomes of Cervical Dural Tears.

Global Spine J 2017 Apr 1;7(1 Suppl):58S-63S. Epub 2017 Apr 1.

Johns Hopkins Hospital, Baltimore, MD, USA.

Study Design: Retrospective multicenter case series study.

Objective: Because cervical dural tears are rare, most surgeons have limited experience with this complication. A multicenter study was performed to better understand the presentation, treatment, and outcomes following cervical dural tears.

Methods: Multiple surgeons from 23 institutions retrospectively identified 21 rare complications that occurred between 2005 and 2011, including unintentional cervical dural tears. Demographic data and surgical history were obtained. Clinical outcomes following surgery were assessed, and any reoperations were recorded. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), Nurick classification (NuC), and Short-Form 36 (SF36) scores were recorded at baseline and final follow-up at certain centers. All data were collected, collated, and analyzed by a private research organization.

Results: There were 109 cases of cervical dural tears among 18 463 surgeries performed. In 101 cases (93%) there was no clinical sequelae following successful dural tear repair. There were statistical improvements ( < .05) in mJOA and NuC scores, but not NDI or SF36 scores. No specific baseline or operative factors were found to be associated with the occurrence of dural tears. In most cases, no further postoperative treatments of the dural tear were required, while there were 13 patients (12%) that required subsequent treatment of cerebrospinal fluid drainage. Analysis of those requiring further treatments did not identify an optimum treatment strategy for cervical dural tears.

Conclusions: In this multicenter study, we report our findings on the largest reported series (n = 109) of cervical dural tears. In a vast majority of cases, no subsequent interventions were required and no clinical sequelae were observed.
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April 2017

Incidence and Outcomes of Acute Implant Extrusion Following Anterior Cervical Spine Surgery.

Global Spine J 2017 Apr 1;7(1 Suppl):40S-45S. Epub 2017 Apr 1.

Cleveland Clinic Foundation, Cleveland, OH, USA.

Study Design: Multi-institutional retrospective case series of 8887 patients who underwent anterior cervical spine surgery.

Objective: Anterior decompression from discectomy or corpectomy is not without risk. Surgical morbidity ranges from 9% to 20% and is likely underreported. Little is known of the incidence and effects of rare complications on functional outcomes following anterior spinal surgery. In this retrospective review, we examined implant extrusions (IEs) following anterior cervical fusion.

Methods: A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of 21 predefined treatment complications.

Results: Following anterior cervical fusion, the incidence of IE ranged from 0.0% to 0.8% across 21 institutions with 11 cases reported. All surgeries involved multiple levels, and 7/11 (64%) involved either multilevel corpectomies or hybrid constructs with at least one adjacent discectomy to a corpectomy. In 7/11 (64%) patients, constructs ended with reconstruction or stabilization at C7. Nine patients required surgery for repair and stabilization following IE. Average length of hospital stay after IE was 5.2 days. Only 2 (18%) had residual deficits after reoperation.

Conclusions: IE is a very rare complication after anterior cervical spine surgery often requiring revision. Constructs requiring multilevel reconstruction, especially at the cervicothoracic junction, have a higher risk for failure, and surgeons should proceed with caution in using an anterior-only approach in these demanding cases. Surgeons can expect most patients to regain function after reoperation.
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April 2017

Epidemiology and Outcomes of Vertebral Artery Injury in 16 582 Cervical Spine Surgery Patients: An AOSpine North America Multicenter Study.

Global Spine J 2017 Apr 1;7(1 Suppl):21S-27S. Epub 2017 Apr 1.

Columbia University, New York, NY, USA.

Study Design: A multicenter retrospective case series was compiled involving 21 medical institutions. Inclusion criteria included patients who underwent cervical spine surgery between 2005 and 2011 and who sustained a vertebral artery injury (VAI).

Objective: To report the frequency, risk factors, outcomes, and management goals of VAI in patients who have undergone cervical spine surgery.

Methods: Patients were evaluated on the basis of condition-specific functional status using the Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) score, the Nurick scale, and the 36-Item Short-Form Health Survey (SF-36).

Results: VAIs were identified in a total of 14 of 16 582 patients screened (8.4 per 10 000). The mean age of patients with VAI was 59 years (±10) with a female predominance (78.6%). Patient diagnoses included myelopathy, radiculopathy, cervical instability, and metastatic disease. VAI was associated with substantial blood loss (770 mL), although only 3 cases required transfusion. Of the 14 cases, 7 occurred with an anterior-only approach, 3 cases with posterior-only approach, and 4 during circumferential approach. Fifty percent of cases of VAI with available preoperative imaging revealed anomalous vessel anatomy during postoperative review. Average length of hospital stay was 10 days (±8). Notably, 13 of the 14 (92.86%) cases resolved without residual deficits. Compared to preoperative baseline NDI, Nurick, mJOA, and SF-36 scores for these patients, there were no observed changes after surgery ( = .20-.94).

Conclusions: Vertebral artery injuries are potentially catastrophic complications that can be sustained from anterior or posterior cervical spine approaches. The data from this study suggest that with proper steps to ensure hemostasis, patients recover function at a high rate and do not exhibit residual deficits.
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April 2017

Thoracic Duct Injury Following Cervical Spine Surgery: A Multicenter Retrospective Review.

Global Spine J 2017 Apr 1;7(1 Suppl):115S-119S. Epub 2017 Apr 1.

Cleveland Clinic, Cleveland, OH, USA.

Study Design: Multicenter retrospective case series.

Objective: To determine the rate of thoracic duct injury during cervical spine operations.

Methods: A retrospective case series study was conducted among 21 high-volume surgical centers to identify instances of thoracic duct injury during anterior cervical spine surgery. Staff at each center abstracted data for each identified case into case report forms. All case report forms were collected by the AOSpine North America Clinical Research Network Methodological Core for data processing, cleaning, and analysis.

Results: Of a total of 9591 patients reviewed that underwent cervical spine surgery, 2 (0.02%) incurred iatrogenic injury to the thoracic duct. Both patients underwent a left-sided anterior cervical discectomy and fusion. The interruption of the thoracic duct was addressed intraoperatively in one patient with no residual postoperative effects. The second individual developed a chylous fluid collection approximately 2 months after the operation that required drainage via needle aspiration.

Conclusions: Damage to the thoracic duct during cervical spine surgery is a relatively rare occurrence. Rapid identification of the disruption of this lymphatic vessel is critical to minimize deleterious effects of this complication.
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April 2017

Rare Complications of Cervical Spine Surgery: Pseudomeningocoele.

Global Spine J 2017 Apr 1;7(1 Suppl):109S-114S. Epub 2017 Apr 1.

University of Virginia, Charlottesville, VA, USA.

Study Design: This study was a retrospective, multicenter cohort study.

Objectives: Rare complications of cervical spine surgery are inherently difficult to investigate. Pseudomeningocoele (PMC), an abnormal collection of cerebrospinal fluid that communicates with the subarachnoid space, is one such complication. In order to evaluate and better understand the incidence, presentation, treatment, and outcome of PMC following cervical spine surgery, we conducted a multicenter study to pool our collective experience.

Methods: This study was a retrospective, multicenter cohort study of patients who underwent cervical spine surgery at any level(s) from C2 to C7, inclusive; were over 18 years of age; and experienced a postoperative PMC.

Results: Thirteen patients (0.08%) developed a postoperative PMC, 6 (46.2%) of whom were female. They had an average age of 48.2 years and stayed in hospital a mean of 11.2 days. Three patients were current smokers, 3 previous smokers, 5 had never smoked, and 2 had unknown smoking status. The majority, 10 (76.9%), were associated with posterior surgery, whereas 3 (23.1%) occurred after an anterior procedure. Myelopathy was the most common indication for operations that were complicated by PMC (46%). Seven patients (53%) required a surgical procedure to address the PMC, whereas the remaining 6 were treated conservatively. All PMCs ultimately resolved or were successfully treated with no residual effects.

Conclusions: PMC is a rare complication of cervical surgery with an incidence of less than 0.1%. They prolong hospital stay. PMCs occurred more frequently in association with posterior approaches. Approximately half of PMCs required surgery and all ultimately resolved without residual neurologic or other long-term effects.
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April 2017

Impact of Preoperative Depression on Hospital Consumer Assessment of Healthcare Providers and Systems Survey Results in a Lumbar Fusion Population.

Spine (Phila Pa 1976) 2017 May;42(9):675-681

Center for Spine Health, Cleveland Clinic, Cleveland, OH.

Study Design: A retrospective cohort study at a single institution.

Objective: To determine the effect of preoperative depression on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores in a lumbar fusion population.

Summary Of Background Data: HCAHPS surveys are used to assess the quality of the patient experience, and directly influences reimbursement for hospital systems and spine surgeons nationwide. Untreated depression has been linked to worse functional outcomes in spine surgery. We, however, aimed to elucidate whether HCAHPS survey responses were different in depressed patients.

Methods: Prospectively collected functional outcome data including Patient Health Questionnaire 9, EuroQol five dimensions, and Pain Disability Questionnaire were analyzed preoperatively. Preoperative Patient Health Questionnaire 9 scores of greater than or equal to 10 (moderate to severe depression) defined our depressed cohort of patients. HCAHPS responses were obtained for each individual, allowing for real-world analysis of outcomes in this population.

Results: In our 237 patient cohort, depressed patients were younger, female; were on full disability; and had lower scores on EuroQol five dimensions and Pain Disability Questionnaire preoperatively. Approximately 73.2% of depressed patients felt doctors treated them with respect, compared to 88.8% of patients without depression (P = 0.005). Also, depressed patients felt nurses treated them with less respect (P = 0.014) and that physicians did not listen to them as carefully (P = 0.029). Multivariate regression analysis revealed that patients with preoperative depression had higher odds of patients feeling less respected by both physicians and nurses. Multivariate analysis also revealed that depression was an independent predictor of lower patient satisfaction with nursing response to their needs.

Conclusion: In patients undergoing lumbar fusion, preoperative depression was shown to have negative effect on patient experience measured by the HCAHPS survey. These results suggest that depression may be a modifiable risk factor for poor hospital experience.

Level Of Evidence: 3.
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May 2017

Erratum: Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center.

Gabriel A Smith

J Neurosurg Spine 2017 03 2;26(3):404. Epub 2016 Dec 2.

Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH.

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March 2017

Primary spinal intradural extramedullary lymphoma: A novel management strategy.

J Clin Neurosci 2017 Jan 10;35:122-126. Epub 2016 Nov 10.

Department of Neurological Surgery, University Hospitals, 11100 Euclid Ave, Cleveland, OH 44122, USA. Electronic address:

Primary spinal intradural extramedullary lymphoma remains a very rare entity in spinal oncology. In this case report, we present the first treatment of a PSIEL diagnosed by cytopathologic analysis alone followed by urgent radio- and chemotherapy in the literature. At 18-month follow-up, our patient was ambulatory with near total imaging resolution of the lesion. In conclusion, surgical excision or biopsy may not be necessary when suspicion for PSIEL exists, and may delay prompt medical and radiation treatment due to necessity for wound healing. Further research into the management of extramedullary lymphoma treatment strategies is warranted.
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January 2017

Incidence, Management, and Outcome of Symptomatic Postoperative Posterior Fossa Pseudomeningocele: A Retrospective Single-Institution Experience.

Oper Neurosurg (Hagerstown) 2016 Sep;12(3):298-304

The Neurological Institute, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.

Background: Pseudomeningocele is a source of considerable morbidity after posterior fossa surgery, but incidence and optimal management strategies are unclear.

Objective: To define risk factors, evaluate management strategies, and identify predictors of resolution.

Methods: A prospectively maintained database of 687 consecutive posterior fossa operations at a single institution was analyzed to identify cases of symptomatic postoperative pseudomeningocele. Retrospective analysis of treatment strategies and outcome was performed.

Results: Overall rate of symptomatic postoperative pseudomeningocele was 14.1% (97 cases). The highest rate was for midline posterior fossa surgery (16.5%), and the lowest rate was for retrosigmoid surgery (11.9%). Multivariate logistic regression analysis revealed that the presence of increased ventricle size on postoperative imaging predicted significantly higher risk of failure of lumbar drainage (odds ratio, 6.57; 95% confidence interval [CI], 1.18-36.59; P < .05). Cox proportional hazards analysis revealed that time to clinical resolution was significantly associated only with use of temporary lumbar drainage (hazards ratio, 2.28; 95% CI, 1.04-5.00; P < .05), and time to radiographic resolution was associated only with placement of a ventricular shunt (hazards ratio, 2.84; 95% CI, 1.19-6.78; P < .05).

Conclusion: Pseudomeningocele is a common complication after posterior fossa surgery, but incidence is not related to age or medical comorbidity. Postoperative ventriculomegaly portends failure of temporary cerebrospinal fluid diversion, and early consideration of shunting might be appropriate in such cases. In the absence of ventriculomegaly, temporary use of a lumbar drain leads to earlier clinical resolution, but complete radiographic resolution is rare when a permanent shunt is not implanted. Further research should be performed to establish the most effective treatment strategy.
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September 2016

Thoracoscopic-Assisted Ventriculo-Azygous Shunt Placement for the Treatment of Hydrocephalus.

Oper Neurosurg (Hagerstown) 2015 Dec;11(4):491-494

Case Western Reserve University School of Medicine, University Hospitals Case Medical Center, Department of Neurological Surgery, Cleveland, Ohio.

Background: Cerebrospinal fluid diversion is one of the most frequent neurosurgical procedures across the world and can be challenging in select patients who fail standard distal drainage sites.

Objective: To present the case of a woman after failing peritoneal, pleural, and atrial distal drainage sites who underwent a thoracoscopic-assisted ventriculo-azygous vein shunt placement.

Methods: A 32-year-old woman presented to our hospital with long-standing history of hydrocephalus and shunt dependence. She had failed peritoneal and atrial shunts secondary to infection, scarring, and clot formation. At presentation, she had a pleural shunt in place and developed a large pleural effusion with shortness of breath.

Results: She was taken to the operating room where a thoracoscopic-assisted ventriculo-azygous vein shunt was placed through a mini-thoracotomy. Postoperatively, she has not required a shunt revision in >2 years of follow-up.

Conclusion: When other distal sites fail, our case report illustrates a novel surgical technique capable of being performed through a multidisciplinary approach.
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December 2015

Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center.

J Neurosurg Spine 2016 Mar 27;24(3):490-5. Epub 2015 Nov 27.

Cleveland Clinic Center for Spine Health, Cleveland, Ohio.

Object: Screening for vertebral artery injury (VAI) following cervical spine fractures is routinely performed across trauma centers in North America. From 2002 to 2007, the total number of neck CT angiography (CTA) studies performed in the Medicare population after trauma increased from 9796 to 115,021. In the era of cost-effective medical care, the authors aimed to evaluate the utility of CTA screening in detecting VAI and reduce chances of posterior circulation strokes after traumatic cervical spine fractures.

Methods: A retrospective review of all patients presenting with cervical spine fractures to Northeast Ohio's Level I trauma institution from 2002 to 2012 was performed.

Results: There was a total of 1717 cervical spine fractures in patients presenting to Northeast Ohio's Level I trauma institution between 2002 and 2012. CTA screening was performed in 732 patients, and 51 patients (0.7%) were found to have a VAI. Fracture patterns with increased odds of VAI were C-1 and C-2 combined fractures, transverse foramen fractures, and subluxation of adjacent vertebral levels. Ten posterior circulation strokes were identified in this patient population (0.6%) and found in only 4 of 51 cases of VAI (7.8%). High-risk fractures defined by Denver Criteria, VAI, and antiplatelet treatment of VAI were not independent predictors of stroke.

Conclusions: Cost-effective screening must be reevaluated in the setting of blunt cervical spine fractures on a case-by-case basis. Further prospective studies must be performed to elucidate the utility of screening for VAI and posterior circulation stroke prevention, if identified.
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March 2016

Holospinal epidural abscess of the spinal axis: two illustrative cases with review of treatment strategies and surgical techniques.

Neurosurg Focus 2014 Aug;37(2):E11

Department of Neurological Surgery, University Hospitals, Case Medical Center;

Despite the increasing prevalence of spinal infections, the subcategory of holospinal epidural abscesses (HEAs) is extremely infrequent and requires unique management. Panspinal imaging (preferably MRI), modern aggressive antibiotic therapy, and prompt surgical intervention remain the standard of care for all spinal axis infections including HEAs; however, the surgical decision making on timing and extent of the procedure still remain ill defined for HEAs. Decompression including skip laminectomies or laminoplasties is described, with varied clinical outcomes. In this review the authors present the illustrative cases of 2 patients with HEAs who were treated using skip laminectomies and epidural catheter irrigation techniques. The discussion highlights different management strategies including the role of conservative (nonsurgical) management in these lesions, especially with an already identified pathogen and the absence of mass effect on MRI or significant neurological defects. Among fewer than 25 case reports of HEA published in the past 25 years, the most important aspect in deciding a role for surgery is the neurological examination. Nearly 20% were treated successfully with medical therapy alone if neurologically intact. None of the reported cases had an associated cranial infection with HEA, because the dural adhesion around the foramen magnum prevented rostral spread of infection. Traditionally a posterior approach to the epidural space with irrigation is performed, unless an extensive focal ventral collection is causing cord compression. Surgical intervention for HEA should be an adjuvant treatment strategy for all acutely deteriorating patients, whereas aspiration of other infected sites like a psoas abscess can determine an infective pathogen, and appropriate antibiotic treatment may avoid surgical intervention in the neurologically intact patient.
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August 2014

Extracranial ligation of ethmoidal arteries before resection of giant olfactory groove or planum sphenoidale meningiomas: 3 illustrative cases with a review of the literature on surgical techniques.

Neurosurg Focus 2013 Dec;35(6):E13

Departments of Neurosurgery and.

Object: There are several surgical techniques for reducing blood loss-open surgical and endoscopic-prior to resection of giant anterior skull base meningiomas, especially when preoperative embolization is risky or not technically feasible. The authors present examples of an institutional experience using surgical ligation of the anterior and posterior ethmoidal arteries producing persistent tumor blush in partially embolized tumors.

Methods: The authors identified 12 patients who underwent extracranial surgical ligation of ethmoidal arteries through either a transcaruncular or a Lynch approach. Of these, 3 patients had giant olfactory groove or planum sphenoidale meningiomas. After approval from the institution privacy officer, the authors studied the medical records and imaging data of these 3 patients, with special attention to surgical technique and outcome. The variations of ethmoidal artery foramina pertaining to this surgical approach were studied using preserved human skulls from the Hamann-Todd Osteological Collection at the Museum of Natural History, Cleveland, Ohio.

Results: The extracranial ligation was performed successfully for control of the ethmoidal arteries prior to resection of hypervascular giant anterior skull base meningiomas. The surgical anatomy and landmarks for ethmoidal arteries were reviewed in anthropology specimens and available literature with reference to described surgical techniques.

Conclusions: Extracranial surgical ligation of anterior, and often posterior, ethmoidal arteries prior to resection of large olfactory groove or planum sphenoidale meningiomas provides a safe and feasible option for control of these vessels prior to either open or endoscopic resection of nonembolized or partially embolized tumors.
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December 2013

Impact of bone morphogenetic proteins on frequency of revision surgery, use of autograft bone, and total hospital charges in surgery for lumbar degenerative disease: review of the Nationwide Inpatient Sample from 2002 to 2008.

Spine J 2014 Jan 5;14(1):20-30. Epub 2012 Dec 5.

Department of Neurosurgery, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA. Electronic address:

Background Context: Bone morphogenetic proteins (BMPs) were developed with the goal of improving clinical outcomes through the promotion of bony healing and reducing morbidity from iliac crest bone graft harvest.

Purpose: To complete a population-based assessment of the impact of BMP on use of autograft, rates of operative treatment for lumbar pseudoarthrosis, and hospital charges.

Study Design: Nationwide Inpatient Sample (NIS) retrospective cohort assessment of 46,452 patients from 2002 to 2008.

Patient Sample: All patients who underwent lumbar arthrodesis procedures for degenerative spinal disease.

Outcome Measures: Use of BMP, revision surgery status as a percentage of total procedures, and autograft harvest in lumbar fusion procedures completed for degenerative diagnoses.

Methods: Demographic and geographic/practice data, hospital charges, and length of stay of all NIS patients with thoracolumbar and lumbosacral procedure codes for degenerative spinal diagnoses were recorded. Codes for autograft harvest, use of BMP, and revision surgery were included in multivariable regression analysis.

Results: The assessment found 46,452 patients from 2002 to 2008 undergoing thoracolumbar or lumbar arthrodesis procedures for degenerative disease. Assuming a representative sample, this cohort models more than 200,000 US patients. There was steady growth in lumbar spine fusion and in the use of BMP. The use of BMP increased from 2002 to 2008 (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.48-1.52). Revision procedures decreased over the study period (OR, 0.94; 95% CI, 0.91-0.96). The use of autograft decreased substantially after introduction of BMP but then returned to baseline levels; there was no net change in autograft use from 2002 to 2008. The use of BMP correlated with significant increases in hospital charges ($13,362.39; standard deviation ± 596.28, p<.00001). The use of BMP in degenerative thoracolumbar procedures potentially added more than $900 million to hospital charges from 2002 to 2008.

Conclusions: There was an overall decrease in rates of revision fusion procedures from 2002 to 2008. Introduction of BMP did not correlate with decrease in use of autograft bone harvest. Use of BMP correlated with substantial increase in hospital charges. The small decrease in revision surgeries recorded, combined with lack of significant change in autograft harvest rates, may question the financial justification for the use of BMP.
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January 2014

Geographic variation and regional trends in adoption of endovascular techniques for cerebral aneurysms.

J Neurosurg 2011 Jun 11;114(6):1768-77. Epub 2011 Feb 11.

Temple University School of Medicine, Philadelphia, Pennsylvania, USA.

Object: Considerable evolution has occurred in treatment options for cerebral aneurysms. Development of endovascular techniques has produced a significant change in the treatment of ruptured and unruptured intracranial aneurysms. Adoption of endovascular techniques and increasing numbers of patients undergoing endovascular treatment may affect health care expenditures. Geographic assessment of growth in endovascular procedures has not been assessed.

Methods: The National Inpatient Sample (NIS) was queried for ICD-9 codes for clipping and coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2008. Patients with ruptured and unruptured cerebral aneurysms were compared according to in-hospital deaths, hospital length of stay, total hospital cost, and selected procedure. Hospital costs were adjusted to bring all costs to 2008 equivalents. Regional variation over the course of the study was explored.

Results: The NIS recorded 12,588 ruptured cerebral aneurysm cases (7318 clipped and 5270 coiled aneurysms) compared with 11,606 unruptured aneurysm cases (5216 clipped and 6390 coiled aneurysms), representing approximately 121,000 aneurysms treated in the study period. Linear regression analysis found that the number of patients treated endovascularly increased over time, with the total number of endovascular patients increasing from 17.28% to 57.59% for ruptured aneurysms and from 29.70% to 62.73% for unruptured aneurysms (p < 0.00001). Patient age, elective status, and comorbidities increased the likelihood of endovascular treatment (p < 0.00001, p < 0.00004, and p < 0.02, respectively). In patients presenting with subarachnoid hemorrhage (SAH), endovascular treatments were more commonly chosen in urban and academic medical centers (p = 0.009 and p = 0.05, respectively). In-hospital deaths decreased over the study period in patients with both ruptured and unruptured aneurysms (p < 0.00001); presentation with SAH remained the single greatest predictor of death (OR 38.09, p < 0.00001). Geographic analysis showed growth in endovascular techniques concentrated in eastern and western coastal states, with substantial variation in adoption of endovascular techniques (range of percentage of endovascular patients [2008] 0%-92%). There were higher costs in patients treated endovascularly, but these differences were likely secondary to presenting diagnosis and site-of-service variations.

Conclusions: The NIS database reveals a significant increase in the use of endovascular techniques, with the majority of both ruptured and unruptured aneurysms treated endovascularly by 2008. Differences in hospital costs between open and endovascular techniques are likely secondary to patient and site-of-service factors. Presentation with SAH was the primary factor affecting hospital cost and a greater percentage of endovascular procedures completed at urban academic medical centers. There is substantial regional variation in the adoption of endovascular techniques.
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June 2011

UDP xylose synthase 1 is required for morphogenesis and histogenesis of the craniofacial skeleton.

Dev Biol 2010 May 11;341(2):400-15. Epub 2010 Mar 11.

Institute of Neuroscience, 1254 University of Oregon, Eugene OR 97403-1254, USA.

UDP-xylose synthase (Uxs1) is strongly conserved from bacteria to humans, but because no mutation has been studied in any animal, we do not understand its roles in development. Furthermore, no crystal structure has been published. Uxs1 synthesizes UDP-xylose, which initiates glycosaminoglycan attachment to a protein core during proteoglycan formation. Crystal structure and biochemical analyses revealed that an R233H substitution mutation in zebrafish uxs1 alters an arginine buried in the dimer interface, thereby destabilizing and, as enzyme assays show, inactivating the enzyme. Homozygous uxs1 mutants lack Alcian blue-positive, proteoglycan-rich extracellular matrix in cartilages of the neurocranium, pharyngeal arches, and pectoral girdle. Transcripts for uxs1 localize to skeletal domains at hatching. GFP-labeled neural crest cells revealed defective organization and morphogenesis of chondrocytes, perichondrium, and bone in uxs1 mutants. Proteoglycans were dramatically reduced and defectively localized in uxs1 mutants. Although col2a1a transcripts over-accumulated in uxs1 mutants, diminished quantities of Col2a1 protein suggested a role for proteoglycans in collagen secretion or localization. Expression of col10a1, indian hedgehog, and patched was disrupted in mutants, reflecting improper chondrocyte/perichondrium signaling. Up-regulation of sox9a, sox9b, and runx2b in mutants suggested a molecular mechanism consistent with a role for proteoglycans in regulating skeletal cell fate. Together, our data reveal time-dependent changes to gene expression in uxs1 mutants that support a signaling role for proteoglycans during at least two distinct phases of skeletal development. These investigations are the first to examine the effect of mutation on the structure and function of Uxs1 protein in any vertebrate embryos, and reveal that Uxs1 activity is essential for the production and organization of skeletal extracellular matrix, with consequent effects on cartilage, perichondral, and bone morphogenesis.
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May 2010