Publications by authors named "Ian A Buchanan"

39 Publications

Readmissions after ventricular shunting in pediatric patients with hydrocephalus: a Nationwide Readmissions Database analysis.

J Neurosurg Pediatr 2021 Aug 20:1-10. Epub 2021 Aug 20.

1Keck School of Medicine, University of Southern California, Los Angeles.

Objective: Cerebrospinal fluid diversion via ventricular shunting is a common surgical treatment for hydrocephalus in the pediatric population. No longitudinal follow-up data for a multistate population-based cohort of pediatric patients undergoing ventricular shunting in the United States have been published. In the current review of a nationwide population-based data set, the authors aimed to assess rates of shunt failure and hospital readmission in pediatric patients undergoing new ventricular shunt placement. They also review patient- and hospital-level factors associated with shunt failure and readmission.

Methods: Included in this study was a population-based sample of pediatric patients with hydrocephalus who, in 2010-2014, had undergone new ventricular shunt placement and had sufficient follow-up, as recorded in the Nationwide Readmissions Database. The authors analyzed the rate of revision within 6 months, readmission rates at 30 and 90 days, and potential factors associated with shunt failure including patient- and hospital-level variables and type of hydrocephalus.

Results: A total of 3520 pediatric patients had undergone initial ventriculoperitoneal shunt placement for hydrocephalus at an index admission. Twenty percent of these patients underwent shunt revision within 6 months. The median time to revision was 44.5 days. Eighteen percent of the patients were readmitted within 30 days and 31% were readmitted within 90 days. Different-hospital readmissions were rare, occurring in ≤ 6% of readmissions. Increased hospital volume was not protective against readmission or shunt revision. Patients with grade 3 or 4 intraventricular hemorrhage were more likely to have shunt malfunctions. Patients who had private insurance and who were treated at a large hospital were less likely to be readmitted.

Conclusions: In a nationwide, population-based database with longitudinal follow-up, shunt failure and readmission were common. Although patient and hospital factors were associated with readmission and shunt failure, system-wide phenomena such as insufficient centralization of care and fragmentation of care were not observed. Efforts to reduce readmissions in pediatric patients undergoing ventricular shunt procedures should focus on coordinating care in patients with complex neurological diseases and on reducing healthcare disparities associated with readmission.
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http://dx.doi.org/10.3171/2021.3.PEDS20794DOI Listing
August 2021

Is There a Difference in Screw Accuracy, Robot Time Per Screw, Robot Abandonment, and Radiation Exposure Between the Mazor X and the Renaissance? A Propensity-Matched Analysis of 1179 Robot-Assisted Screws.

Global Spine J 2021 Jul 8:21925682211029867. Epub 2021 Jul 8.

Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA.

Study Design: Prospective single-cohort analysis.

Objectives: To compare the outcomes/complications of 2 robotic systems for spine surgery.

Methods: Adult patients (≥18-years-old) who underwent robot-assisted spine surgery from 2016-2019 were assessed. A propensity score matching (PSM) algorithm was used to match Mazor X to Renaissance cases. Preoperative CT scan for planning and an intraoperative O-arm for screw evaluation were preformed. Outcomes included screw accuracy, robot time/screw, robot abandonment, and radiation. Screw accuracy was measured using Vitrea Core software by 2 orthopedic surgeons. Screw breach was measured according to the Gertzbein/Robbins classification.

Results: After PSA, a total of 65 patients (Renaissance: 22 vs. X: 43) were included. Patient/operative factors were similar between robot systems ( > .05). The pedicle screw accuracy was similar between robots (Renaissance: 1.1%% vs. X: 1.3%, = .786); however, the S2AI screw breach rate was significantly lower for the X (Renaissance: 9.5% vs. X: 1.2%, = .025). Robot time per screw was not statistically different (Renaissance: 4.6 minutes vs. X: 3.9 minutes, = .246). The X was more reliable with an abandonment rate of 2.3% vs. Renaissance:22.7%, = .007. Radiation exposure were not different between robot systems. Non-robot related complications including dural tear, loss of motor/sensory function, and blood transfusion were similar between robot systems.

Conclusion: This is the first comparative analyses of screw accuracy, robot time/screw, robot abandonment, and radiation exposure between the Mazor X and Renaissance systems. There are substantial improvements in the X robot, particularly in the perioperative planning processes, which likely contribute to the X's superiority in S2AI screw accuracy by nearly 8-fold and robot reliability by nearly 10-fold.
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http://dx.doi.org/10.1177/21925682211029867DOI Listing
July 2021

Lumbar discectomies in elite rowers: presentation, operative treatment, and return to play.

Phys Sportsmed 2021 Aug 8:1-5. Epub 2021 Aug 8.

Department of Orthopaedic Surgery, Columbia University Medical Center, the Spine Hospital at New York Presbyterian, New York, NY, USA.

Objective: In a cohort of elite rowers requiring lumbar spine surgery, we report information regarding: (1) presentation, (2) operative treatment, and (3) return to play (RTP).

Methods: All competitive rowers undergoing spine surgery at a single academic institution from 2015 to 2020 were analyzed. Three rowers underwent spine surgery during the allotted time period. Demographic, clinical, operative, and RTP data was recorded. Each athlete's self-reported level of effort/performance was assessed before and after surgery. First RTP was defined as the time of initial return to rowing activities, and full RTP was defined as the time of unrestricted return to rowing activities. Descriptive statistics were performed.

Results: The three collegiate rowers ranged from 20- to 21-year-old, each with L5/S1 disc herniations. Preoperative pain levels ranged from 8 to 10, and inciting injury events included back squats, front squats, and rowing during the 'finish' stage. Each athlete underwent a minimally invasive, unilateral L5/S1 decompression, partial medial facetectomy, and partial discectomy with microscopic-assistance. First RTP ranged from 4-6 months, with full RTP at 6-8 months. Pain dissipated to the 0-1 range at full RTP. Final effort/performance improved from 10-60% mid-injury to 90-100% at full RTP. Each athlete's 2000m row time showed a decline mid-injury and an improvement to at or within 10 s of their pre-injury time.

Conclusions: Drawing from three collegiate rowers who underwent lumbar decompression surgery, each athlete successfully returned to rowing, with initial RTP in the 4-6 months range and full RTP in the 6-8 months range. Performance levels rebounded to near or better than pre-injury performance. The results of this small case series warrant replication in larger, multi-institutional samples.
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http://dx.doi.org/10.1080/00913847.2021.1948309DOI Listing
August 2021

What is the Comparison in Robot Time per Screw, Radiation Exposure, Robot Abandonment, Screw Accuracy, and Clinical Outcomes Between Percutaneous and Open Robot-Assisted Short Lumbar Fusion? A Multicenter, Propensity-Matched Analysis of 310 Patients.

Spine (Phila Pa 1976) 2021 Jun 4. Epub 2021 Jun 4.

Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA Department of Neurosurgery, State University of New York, Buffalo, NY, USA Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA.

Study Design: Multicenter cohort.

Objective: To compare the robot time/screw, radiation exposure, robot abandonment, screw accuracy, and 90-day outcomes between robot-assisted percutaneous and robot-assisted open approach for short lumbar fusion (1-and 2-level).

Summary Of Background Data: There is conflicting literature on the superiority of robot-assisted minimally invasive spine surgery to open techniques. A large, multicenter study is needed to further elucidate the outcomes and complications between these two approaches.

Methods: We included adult patients (≥18 years old) who underwent robot-assisted short lumbar fusion surgery from 2015-2019 at four independent institutions. A propensity score matching (PSM) algorithm was employed to control for the potential selection bias between percutaneous and open surgery. The minimum follow-up was 90 days after the index surgery.

Results: After PSM, 310 patients remained. The mean (standard deviation) charlson comorbidity index was 1.6 (1.5) and 53% of patients were female. The most common diagnoses included high grade spondylolisthesis (grade >2)(48%), degenerative disc disease (22%), and spinal stenosis (25%), and the mean number of instrumented levels was 1.5(0.5). The operative time was longer in the open (198 minutes) vs. the percutaneous group (167 minutes, P-value=0.007). However, the robot time/screw was similar between cohorts (P-value>0.05). The fluoroscopy time/screw for percutaneous (14.4 seconds) was longer than the open group (10.1 seconds, P-value=0.021). The rates for screw exchange and robot abandonment, were similar between groups (P-value>0.05). The estimated blood loss (open:146 mL vs. percutaneous:61.3 mL, P-value < 0.001) and transfusion rate (open:3.9% vs. percutaneous:0%, P-value=0.013) were greater for the open group. The 90-day complication rate and mean length of stay were not different between cohorts(P-value>0.05).

Conclusion: Percutaneous robot-assisted spine surgery may increase radiation exposure, but can achieve a shorter operative time and lower risk for intraoperative blood loss for short-lumbar fusion. Percutaneous approaches do not appear to have an advantage for other short-term postoperative outcomes. Future multicenter studies on longer fusion surgeries and the inclusion of patient-reported outcomes are needed.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000004132DOI Listing
June 2021

Do Adult Spinal Deformity Patients Undergoing Surgery Continue to Improve From 1-Year to 2-Years Postoperative?

Global Spine J 2021 May 26:21925682211019352. Epub 2021 May 26.

Department of Orthopaedic Surgery, 21611Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, NY, USA.

Objective: Evaluate clinical improvement as measured by patient-reported outcomes (PROs) during the 1 to 2-year interval.

Study Design: Retrospective Cohort.

Methods: A single-institution registry of ASD patients undergoing surgery was queried for patients with ≥6 level fusions. Demographics and radiographic variables were collected. PROs collected were the ODI and SRS-22r scores at: preoperative, 1-year and 2-years. Outcome measures of clinical improvement during the 1-2 year time interval were: 1) group medians, 2) percent minimum clinically important difference (MCID), and 3) percent minimal symptom scale (MSS)(ODI < 20 or SRS-pain + function >8). Wilcoxon rank-sum tests, chi-squared tests, Kruskal-Wallis tests, and logistic regression were performed.

Results: 157 patients undergoing ASD surgery with minimum of 1-year follow-up were included. Mean age was 53.2 and mean instrumented levels was 13.1. Preoperative alignment was: Neutral Alignment (NA) 49%, Coronal Malalignment (CM) 17%, Sagittal Malalignment (SM 17%), and Combined Coronal/Sagittal Malalignment (CCSM) 18%. Preoperative to 1-year, and preoperative to 2-years, all ODI/SRS-22r significantly improved ( < .001). the only significant improvement in PROs between 1-and 2-year postoperative were those reaching ODI MCID (69% 1-year vs. 84% 2-years; < .001). ≥55 years had an improved median ODI (18 vs. 8; = .047) and an improved percent achieving ODI MCID (73% vs. 84%, = .048). CCSM patients experienced significant improvement in SRS-appearance score (75% vs. 100%; = .050), along with those with severe preoperative SM >7.5 cm (73% vs. 100%; = .032).

Conclusions: Most ASD patients experience the majority of PRO improvement by 1-year postoperative. However, subsets of patients that may continue to improve up to 2-years postoperative include patients ≥55 years, combined coronal/sagittal malalignment, and those with severe sagittal malalignment ≥7.5 cm.
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http://dx.doi.org/10.1177/21925682211019352DOI Listing
May 2021

Is there a difference between navigated and non-navigated robot cohorts in robot-assisted spine surgery? A multicenter, propensity-matched analysis of 2,800 screws and 372 patients.

Spine J 2021 Sep 19;21(9):1504-1512. Epub 2021 May 19.

Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA.

Background Context: Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes.

Purpose: To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition.

Study Design: Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms.

Outcome Measures: Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up.

Methods: A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively.

Results: From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456).

Conclusion: In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar.
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http://dx.doi.org/10.1016/j.spinee.2021.05.015DOI Listing
September 2021

The odontoid-CSVL distance in a global population of asymptomatic volunteers: normative values and implications for spinal coronal alignment.

Eur Spine J 2021 May 19. Epub 2021 May 19.

Department of Orthopedic Surgery, Columbia University Medical Center, The Och Spine Hospital at New York Presbyterian, New York, USA.

Purpose: In a population of asymptomatic volunteers across 5 countries, we sought to: (a) establish normative values of the Odontoid-Central Sacral Vertical Line (OD-CSVL) across patient factors, and (b) assess correlations of OD-CSVL with other radiographic parameters.

Methods: A prospective, cross-sectional study of asymptomatic adult volunteers, ages 18-80 years, were enrolled across 5 countries (France, Japan, Singapore, Tunisia, United States) forming the Multi-Ethnic Alignment Normative Study (MEANS) cohort. Included volunteers had no known spinal disorder(s), no significant neck/back pain (VAS ≤ 2; ODI ≤ 20), and no significant scoliosis (Cobb ≤ 20°). Radiographic measurements included commonly used coronal alignment parameters (mm) and angles (°). OD-CSVL was defined as the difference between the odontoid plumb line (line from the tip of the odontoid vertically down) and the CSVL (vertical line from the center of the sacrum). Chi-square, student's t tests, Kruskal-Wallis, Wilcoxon rank-sum, linear regression, and Pearson's correlation were used with significance at p < 0.05.

Results: 467 volunteers were included with normative OD-CSVL values by age decade, gender, BMI, and country. Mean ± SD OD-CSVL was 8.3 mm ± 6.5 mm and 31 (6.6%) volunteers were almost perfectly aligned (OD-CSVL < 1 mm). A linear relationship was seen between OD-CSVL with both age (p < 0.001) and BMI (p = 0.015). Significant variation was seen between OD-CSVL and 5 different ethnicities (p = 0.004). OD-CSVL correlated best with other coronal radiographic parameters, C7-CSVL (r = 0.743, p < 0.001), OD-knee (r = 0.230, p < 0.001), CAM-knee (r = 0.612, p < 0.001), and regional TL cobb angle (r = 0.4214, p = 0.005).

Conclusion: Among asymptomatic volunteers, increased OD-CSVL was significantly associated with increased age, increased BMI, and ethnicity, but not gender. OD-CSVL correlated strongest with C7-CSVL, TL cobb angle, OD-knee, and CAM-knee. OD-CSVL. These results support further study of OD-CSVL in symptomatic adult spine deformity patients.
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http://dx.doi.org/10.1007/s00586-021-06873-6DOI Listing
May 2021

Do robot-related complications influence 1 year reoperations and other clinical outcomes after robot-assisted lumbar arthrodesis? A multicenter assessment of 320 patients.

J Orthop Surg Res 2021 May 12;16(1):308. Epub 2021 May 12.

Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA.

Background: Robot-assisted platforms in spine surgery have rapidly developed into an attractive technology for both the surgeon and patient. Although current literature is promising, more clinical data is needed. The purpose of this paper is to determine the effect of robot-related complications on clinical outcomes METHODS: This multicenter study included adult (≥18 years old) patients who underwent robot-assisted lumbar fusion surgery from 2012-2019. The minimum follow-up was 1 year after surgery. Both bivariate and multivariate analyses were performed to determine if robot-related factors were associated with reoperation within 1 year after primary surgery.

Results: A total of 320 patients were included in this study. The mean (standard deviation) Charlson Comorbidity Index was 1.2 (1.2) and 52.5% of patients were female. Intraoperative robot complications occurred in 3.4% of patients and included intraoperative exchange of screw (0.9%), robot abandonment (2.5%), and return to the operating room for screw exchange (1.3%). The 1-year reoperation rate was 4.4%. Robot factors, including robot time per screw, open vs. percutaneous, and robot system, were not statistically different between those who required revision surgery and those who did not (P>0.05). Patients with robot complications were more likely to have prolonged length of hospital stay and blood transfusion, but were not at higher risk for 1-year reoperations. The most common reasons for reoperation were wound complications (2.2%) and persistent symptoms due to inadequate decompression (1.5%). In the multivariate analysis, robot related factors and complications were not independent risk factors for 1-year reoperations.

Conclusion: This is the largest multicenter study to focus on robot-assisted lumbar fusion outcomes. Our findings demonstrate that 1-year reoperation rates are low and do not appear to be influenced by robot-related factors and complications; however, robot-related complications may increase the risk for greater blood loss requiring a blood transfusion and longer length of stay.
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http://dx.doi.org/10.1186/s13018-021-02452-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8114480PMC
May 2021

Evaluation of facet joints and segmental motion in patients with different grades of L5/S1 intervertebral disc degeneration: a kinematic MRI study.

Eur Spine J 2020 10 5;29(10):2609-2618. Epub 2020 Jun 5.

Department Orthopaedic Surgery, Keck School of Medicine, University of Southern California, 1540 Alcazar Street, CHP 207, Los Angeles, CA, 90033, USA.

Purpose: This study aimed to evaluate facet joint parameters and osteoarthritis grades, and segmental angular and translational motions among different grades of L5/S1 intervertebral disc (IVD) degeneration.

Methods: This retrospective study analysed kinematic magnetic resonance imaging (kMRI) images of the lumbar spine of 214 patients with low back pain. Degenerations of the L5/S1 IVDs and facet joints osteoarthritis were assessed using the Pfirrmann and Pathria grading scales, respectively. Facet joint parameters included facet joint angle and facet joint space width. Angular and translation segmental motions were measured using MRI Analyzer software.

Results: The mean age of the studied patients was 44.1 ± 13.9 years. Patients with L5/S1 disc degeneration were associated with higher odds of facet joint osteoarthritis (odds ratio = 2.28, 95% confidence interval = 1.23-4.23, P = 0.008). There was a positive correlation between L5/S1 disc degeneration grade and the facet joint grade (r = 0.365, P > 0.001). Grade IV facet joint osteoarthritis did not appear in grades I or II disc degeneration (P > 0.001). The average facet joint width decreased significantly with increasing Pfirrmann grading (P = 0.017). The difference in facet joint angle between groups was not statistically significant (P = 0.532). The differences in the angular and translational motions were not statistically significant (P = 0.530, and 0.510, respectively).

Conclusion: A positive correlation exists between L5/S1 disc degeneration and facet joint osteoarthritis grades. The facet joint space width decreases significantly with increasing grade of disc degeneration.
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http://dx.doi.org/10.1007/s00586-020-06482-9DOI Listing
October 2020

Intra- and Post-Complications of Cervical Laminoplasty for the Treatment of Cervical Myelopathy: An Analysis of a Nationwide Database.

Spine (Phila Pa 1976) 2020 Oct;45(20):E1302-E1311

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Study Design: Retrospective database study.

Objective: To assess the intra- and postoperative complications of cervical laminoplasty and to evaluate the effect of intraoperative neuromonitoring use on postoperative limb paralysis incidence.

Summary Of Background Data: Cervical laminoplasty is a known procedure for the management of cervical spondylotic myelopathy (CSM).

Methods: This was a retrospective study of 532 patients with CSM who underwent cervical laminoplasty between 2007 and the first quarter of 2016 using the Humana subset of the PearlDiver Database. The database was queried using the relevant International Classification of Diseases (ICD-9 and ICD-10) codes for CSM and Current Procedural Terminology (CPT) codes for cervical laminoplasty. The intra- and postoperative incidence of surgical and medical complications and reoperations was then determined and was compared with a propensity score-matched cohort of patients who had posterior laminectomy and fusion (490 patients in each group), using multivariate logistic regression analysis.

Results: Laminoplasty was associated with a lower incidence of dysphagia (odds ratio [OR] = 0.37, 95% confidence interval [CI] = 0.16-0.79; P = 0.014), 30-day readmission (OR = 0.51, 95% CI = 0.35-0.75; P < 0.001), urinary tract infection (OR = 0.58, 95% CI = 0.37-0.93; P = 0.023), and incision and drainage, exploration or evacuation (OR = 0.28, 95% CI = 0.08-0.79; P = 0.026). The use of intraoperative neuromonitoring was associated with a non-significant lower incidence of limb paralysis within 1 and 3 months postoperatively (OR = 0.52 and 0.51, 95% CI = 0.23-1.19 and 0.23-1.11; P = 0.119 and 0.091, respectively).

Conclusion: Compared with posterior laminectomy and fusion, laminoplasty had lower rates of dysphagia, urinary tract infection, and 30-day readmission. The use of intraoperative neuromonitoring was associated with a lower risk of postoperative limb paralysis, but it did not achieve statistical significance.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000003574DOI Listing
October 2020

Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base.

Laryngoscope 2021 03 25;131(3):462-466. Epub 2020 May 25.

Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California, U.S.A.

Objectives/hypothesis: Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail.

Study Design: Retrospective case series.

Methods: The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis.

Results: Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground-glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground-glass opacities on imaging resolved in all six cases.

Conclusions: Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment.

Level Of Evidence: 4 Laryngoscope, 131:462-466, 2021.
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http://dx.doi.org/10.1002/lary.28757DOI Listing
March 2021

Use of a Reverse Bohlman Technique for Low-Grade Spondylolisthesis.

Int J Spine Surg 2019 Oct 31;13(5):486-491. Epub 2019 Oct 31.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background: Treatment of spondylolisthesis can be difficult with regard to patients with high sacral slopes that may prohibit placement of interbody grafts for fusions across that segment. Here, we describe placement of a reverse Bohlman technique from an anterior approach to obtain fusion across a low-grade spondylolisthesis with a high sacral slope to obtain anterior fusion.

Methods: A chart review was conducted on this single patient regarding his clinical course and outcome.

Results: A 54-year-old male presented with low-back pain associated with bilateral leg pain dating back several years. Plain films demonstrated a Grade II isthmic spondylolisthesis at L5-S1 with spinopelvic measurements of 73° sacral slope, 82° lumbar lordosis, 12° pelvic tilt, and 94° pelvic incidence. Magnetic resonance imaging showed bilateral L5 pars defects with diffuse degenerative disease from L4 through S1 and significant ligamentous and facet hypertrophy. He underwent an L4-5 anterior lumbar interbody fusion and an L5-S1 reverse Bohlman placement of a transvertebral transsacral titanium mesh cage. This was supplemented with a posterior decompression and instrumentation from L4-ilium. He had resolution of his radiculopathy and has maintained a good clinical outcome at 3 years follow up.

Conclusions: We present here a patient with low-grade spondylolisthesis and a steep sacral slope who underwent a successful reverse Bohlman approach with long-term follow up. This report highlights the potential utility of this method as a viable alternative for patients with low-grade spondylolisthesis.

Level Of Evidence: IV.

Clinical Relevance: Technical description of surgical technique.
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http://dx.doi.org/10.14444/6065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6836877PMC
October 2019

Readmission following inpatient stereotactic radiosurgery for brain tumors.

J Radiosurg SBRT 2019 ;6(2):101-119

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street Suite 3300, Los Angeles, CA 90033, USA.

Background: Stereotactic radiosurgery (SRS) is indicated for a spectrum of brain tumors and is often an outpatient procedure, though severe disease may precipitate inpatient treatment. Readmission following inpatient SRS for brain tumors is not well understood.

Objectives: To characterize rate, associative factors, and predictors of SRS readmission.

Methods: Retrospective analysis of inpatients treated with SRS for brain neoplasms was conducted (2010-2014 Nationwide Readmissions Database). Diagnoses upon readmission were characterized. Associations with 30-day readmission were identified using multivariate analyses.

Results: Of 2,553 patients undergoing SRS, 390 were readmitted (15.3%) within 30 days. Leading readmission diagnoses were infectious or embolic. Neurological readmissions of intracerebral hemorrhage (2.1%) and cerebral edema (1.5%) were rare. Malignant tumors (OR=1.60, p=0.007) and discharge to facility (OR=1.41, p=0.004) were associated with readmission.

Conclusion: Inpatients receiving SRS for brain tumors have a 15.3% 30-day readmission rate. Neurologic readmissions were rare, underscoring the neurological safety of SRS, even in sick inpatients.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6774493PMC
January 2019

State of the Union in Open Neurovascular Training.

World Neurosurg 2019 02 26;122:e553-e560. Epub 2018 Oct 26.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA.

Background: The evolution of minimally invasive endovascular approaches and training paradigms has reduced open neurovascular case exposure for neurosurgical residents. There are no published estimates of open neurovascular case volumes during residency or Committee on Advanced Subspecialty Training (CAST) accredited fellowships.

Methods: Case volumes from residency programs submitting data for CAST accredited fellowship applications were collected and analyzed. The study period covered the academic years of 2013-2016. Case index volumes were calculated to provide an estimate of total volume of cases each trainee participated in a given year. The case index volume was defined as the total volume of cases per year divided by the total training complement.

Results: Over the study period, institutional data from 46 programs were available. Of those programs, 9 programs had CAST accredited open cerebrovascular fellowships. Across all 46 programs, the median number of vascular cases was 246 (interquartile range [IQR]: 148-340), whereas the median number of open vascular cases was 105 (IQR: 67-152). The median number of open aneurysm cases among programs with CAST cerebrovascular fellowships was 80 (IQR: 54-103) and among programs without CAST cerebrovascular fellowships was 34 (IQR: 24-63). The median open aneurysm case index volume for trainees at programs with and without CAST cerebrovascular fellowships was 23 (IQR: 14-29) and 19 (IQR: 11-24).

Conclusions: Strong neurovascular training can be obtained through dedication and planning. Completion of a CAST accredited cerebrovascular fellowship will often more than double aneurysm case exposure of trainees.
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http://dx.doi.org/10.1016/j.wneu.2018.10.099DOI Listing
February 2019

Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis.

World Neurosurg 2019 Aug 28;128:e38-e50. Epub 2019 Mar 28.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Ventricular shunting is one of the primary modalities for addressing hydrocephalus in both children and adults. Despite advances in shunt technology and surgical practices, shunt failure is a persistent challenge for neurosurgeons, and shunt revisions account for a substantial proportion of all shunt-related procedures. There are a wealth of studies elucidating failure patterns and patient demographics in pediatric cohorts; however, data in adults are less uniform. We sought to determine the rates of all-cause and shunt failure readmission in adults who underwent the insertion of a ventricular shunt.

Methods: We queried the Nationwide Readmissions Database from 2010 to 2014 to evaluate new ventricular shunts placed in adults with hydrocephalus. We sought to determine the rates of all-cause and shunt revision-related readmissions and to characterize factors associated with readmissions. We analyzed predictors including patient demographics, hospital characteristics, shunt type, and hydrocephalus cause.

Results: Analysis included 24,492 initial admissions for shunt placement in patients with hydrocephalus. Of patients, 9.17% required a shunt revision within the first 6 months; half of all revisions occurred within the first 41 days. There were 4044 (16.50%) 30-day and 5758 (28.8%) 90-day all-cause readmissions. In multivariable analysis, patients with a ventriculopleural shunt, Medicare insurance, and younger age had increased likelihood for shunt revision. Notable predictors for all-cause readmission were insurance type, length of hospitalization, age, comorbidities, and hydrocephalus cause.

Conclusions: Most shunt revisions occurred during the first 2 months. Readmissions occurred frequently. We identified patient factors that were associated with all-cause and shunt failure readmissions.
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http://dx.doi.org/10.1016/j.wneu.2019.03.217DOI Listing
August 2019

Simulation of Dural Repair in Minimally Invasive Spine Surgery With the Use of a Perfusion-Based Cadaveric Model.

Oper Neurosurg (Hagerstown) 2019 12;17(6):616-621

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background And Importance: In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees.

Objective: To simulate dural repair in spine surgery using minimal-access techniques.

Methods: A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model.

Results: Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees-irrespective of postgraduate year-were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores.

Conclusion: Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.
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http://dx.doi.org/10.1093/ons/opz041DOI Listing
December 2019

Costs and training results of an objectively validated cadaveric perfusion-based internal carotid artery injury simulation during endoscopic skull base surgery.

Int Forum Allergy Rhinol 2019 07 18;9(7):787-794. Epub 2019 Mar 18.

Tina and Rick Caruso Department of Otorhinolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Background: Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches (EEAs). High-fidelity simulation methods exist, but optimization of the training cohort, training paradigm, and costs of simulation training remain unknown.

Methods: Using our previously validated, high-fidelity, perfused-cadaver model, participants attempted to manage a simulated ICAI. After a brief instructional video and coaching, the simulation was repeated. Training success was defined as successful ICAI control on the second attempt after failure on the initial attempt. Marginal costs were measured.

Results: Seventy-two surgeons participated in the standardized simulation, which lasted ≤15 minutes. The marginal cost of simulation was $275.00 per surgeon. A total of 44.4% (n = 32) succeeded on the first attempt before training (previously proficient); 44.4% (n = 32) failed the first attempt, but succeeded after training (training successes); and 11.1% (n = 8) failed both attempts. The cost per training success was $618.75. Forty-two surgeons had never treated an ICAI, with 24 becoming training successes (57.1% overall, 82.8% when excluding previously proficient surgeons). Twenty-nine had experienced a real or simulated ICAI, with 8 (27.6% overall, 72.7% excluding previously proficient surgeons) becoming training successes. The cost per training success was lowest in the ICAI-naive group ($481.25) and highest among surgeons with simulated and real ICAI experience ($1650).

Conclusions: Surgeons can be trained to manage ICAI in a single, brief, low-cost session. Although all groups improved, training an ICAI-naive or resident cohort may maximize training results. A perfused-cadaver model is a reproducible, realistic, and low-cost method for training surgeons to manage life-threatening ICAI during an EEA.
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http://dx.doi.org/10.1002/alr.22319DOI Listing
July 2019

Transpedicular lag screw placement in traumatic cervical spondylolisthesis: Case report and systematic review of the literature.

J Clin Neurosci 2019 May 5;63:256-262. Epub 2019 Feb 5.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States. Electronic address:

Traumatic spondylolisthesis of C2-C3 is an unstable fracture. Posterior fixation techniques can be employed with intraoperative navigation, however this tool is not available to all spine surgeons. Furthermore, the evidence for posterior surgical stabilization of C2, while adhering to motion preservation principles is currently unknown. The authors describe a patient who had fractures of the pedicle and vertebral body of C2 and C3, which was successfully stabilized with freehand placement of C2 pedicle lag screws and subsequent C2-C5 fixation. Subsequently, a systematic review was performed to evaluate studies that utilized C2 lag screw placement in patients with traumatic spondylolisthesis of the axis (TSA). Eight retrospective case series were identified (N = 63 patients). Five studies evaluated an open posterior cervical approach and 3 investigated a percutaneous approach. Follow-up time ranged from 2 to 48 months and fusion was successful in most cases. No intra-operative complications were reported. On final follow-up, 2 patients had unintentional C2-C3 fusion, and 3 had C2-C3 instability. Three minor complications (urinary tract infection, surgical site hematoma, respiratory infection) were also reported, that resolved with medical management. Freehand placement of C2 pedicle lag screws may be a viable option in select cases. While posterior C2 lag-screw fixation demonstrated successful fusion in most patients with TSA, the supporting evidence is limited to level IV studies.
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http://dx.doi.org/10.1016/j.jocn.2019.01.036DOI Listing
May 2019

Venous Thromboembolism After Degenerative Spine Surgery: A Nationwide Readmissions Database Analysis.

World Neurosurg 2019 05 23;125:e165-e174. Epub 2019 Jan 23.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Venous thromboembolism (VTE) is an appreciable burden on health care. The protracted recumbency experienced by many spinal patients juxtaposed with concerns for postoperative hemorrhage from early anticoagulation results in conflicting stances regarding chemoprophylaxis. Identifying risk factors associated with VTE is therefore instrumental in guiding management.

Objective: To identify VTE risk factors in patients undergoing degenerative spine surgery.

Methods: The Nationwide Readmissions Database was searched for adults undergoing spine surgery for degenerative diseases between 2010 and 2014. The 30-day and 90-day VTE incidence was estimated from readmissions with new VTE diagnoses. A multivariate survey-adjusted logistic regression model was used to identify variables associated with VTE diagnoses on readmission.

Results: Of 838,507 degenerative spine cases queried, 3499 patients (0.42%) were readmitted with a VTE diagnosis within 30 days and 4321 patients (0.62%) were readmitted within 90 days. In multivariate analysis, steroids were independently associated with a higher likelihood of readmission with VTE at both 30 days (odds ratio, 1.58; P < 0.001) and 90 days (odds ratio, 1.97; P < 0.001). Significant associations were also identified with thoracolumbar surgery, length of stay, and discharge to institutional care.

Conclusions: The incidence of readmission with VTE diagnoses in spine surgery is low. However, their devastating consequences underscore the need to identify those patients deemed high risk. These patients include those having thoracolumbar surgery, of advanced age, with prolonged length of stay, using corticosteroids, and with a disposition to institutional care (e.g., skilled nursing facility or long-term acute care). Given the association between steroids and VTE, clinicians should be judicious about perioperative administration despite their obvious antiinflammatory benefits.
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http://dx.doi.org/10.1016/j.wneu.2019.01.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650385PMC
May 2019

Postoperative Antiplatelet Therapy in the Treatment of Complex Basilar Apex Aneurysms Implementing Hunterian Ligation and Extracranial-to-Intracranial Bypass: Review of the Literature with an Illustrative Case Report.

World Neurosurg 2019 Mar 8;123:113-122. Epub 2018 Dec 8.

Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. Electronic address:

Large broad-based basilar artery (BA) apex aneurysms involving multiple arterial origins are complex lesions commonly not amenable to direct clipping or endovascular management. BA proximal (Hunterian) occlusion with extracranial-to-intracranial bypass is a supported strategy if 1 or both posterior communicating arteries are small. Hunterian ligation risks sudden aneurysm thrombosis and thromboembolism in the perforator-rich BA apex. There currently exist no guidelines for antiplatelet and anticoagulant therapy after Hunterian ligation for complex BA apex aneurysm treatment. We present a literature review and an illustrative case of an 18-year-old man who presented with progressive headaches and was found to have a large unruptured BA apex aneurysm involving the origins of the bilateral superior cerebellar and posterior cerebral arteries. Given the small posterior communicating arteries and complexity of the aneurysm, proximal BA occlusion with unilateral superficial temporal artery-to-superior cerebellar artery bypass was recommended. Despite antiplatelet treatment with acetylsalicylic acid before and after operation, the patient experienced acute ischemia of the brainstem and cerebellum and an embolic left temporal lobe infarct. The patient received dual antiplatelet therapy starting on postoperative day 6, after which he experienced no new infarcts and made a significant neurologic recovery. The current evidence suggests that proximal BA occlusion in complex BA apex aneurysm cases is thrombogenic and can be especially dangerous if thrombosis occurs suddenly in aneurysms without pre-existing intraluminal thrombus. Dual antiplatelet therapy during the first postoperative week presents a possible strategy for reducing the risk of ischemia due to sudden aneurysm thrombosis.
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http://dx.doi.org/10.1016/j.wneu.2018.11.237DOI Listing
March 2019

Predictors of Venous Thromboembolism After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

World Neurosurg 2019 Feb 20;122:e1102-e1110. Epub 2018 Nov 20.

Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Venous thromboembolism (VTE) is responsible for many hospital readmissions each year, particularly among postsurgical cohorts. Because early and indiscriminate VTE prophylaxis carries catastrophic consequences in postcraniotomy cohorts, identifying factors associated with a high risk for thromboembolic complications is important for guiding postoperative management.

Objective: To determine VTE incidence in patients undergoing nonemergent craniotomy and to evaluate for factors that predict 30-day and 90-day readmission with VTE.

Methods: The 2010-2014 cohorts of the Nationwide Readmissions Database were used to generate a large heterogeneous craniotomy sample.

Results: There were 89,450 nonemergent craniotomies that met inclusion criteria. Within 30 days, 1513 patients (1.69%) were readmitted with VTE diagnoses; among them, 678 (44.8%) had a diagnosis of deep vein thrombosis alone, 450 (29.7%) had pulmonary embolism alone, and 385 (25.4%) had both. The corresponding 30-day deep vein thrombosis and pulmonary embolism incidences were 1.19% and 0.93%, respectively. In multivariate analysis, several factors were significantly associated with VTE readmission, namely, craniotomy for tumor, corticosteroids, advanced age, greater length of stay, and discharge to institutional care.

Conclusions: Craniotomies for tumor, corticosteroids, advanced age, prolonged length of stay, and discharge to institutional care are significant predictors of VTE readmission. The implication of steroids, coupled with their ubiquity in neurosurgery, makes them a potentially modifiable risk factor and a prime target for VTE reduction in craniotomy cohorts. Furthermore, the fact that dose is proportional to VTE risk in the literature suggests that careful consideration should be given toward decreasing regimens in situations in which use of a lower dose might prove equally sufficient.
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http://dx.doi.org/10.1016/j.wneu.2018.10.237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363858PMC
February 2019

Treatment at Safety-Net Hospitals Is Associated with Delays in Coil Embolization in Patients with Subarachnoid Hemorrhage.

World Neurosurg 2018 Dec 8;120:e434-e439. Epub 2018 Sep 8.

Department of Neurological Surgery, University of Southern California, Los Angeles, California.

Background: Successful endovascular management of aneurysmal subarachnoid hemorrhage (aSAH) requires timely access to substantial resources. Prior studies suggest an association between time to treatment and patient outcome. Patients treated at safety-net hospitals are thought to be particularly vulnerable to disparities in access to interventions that require substantial technologic resources. We hypothesized that patients with aSAH treated at safety-net hospitals are at greater risk for delayed access to endovascular treatment.

Methods: Adults undergoing endovascular coiling procedures between 2002 and 2011 in the Nationwide Inpatient Sample were included. Hospitals in the quartile with the highest proportion of Medicaid or uninsured patients were defined as safety-net hospitals. A multivariate model including patient-level and hospital-level factors was constructed to permit analysis of delays in endovascular treatment (defined as time to treatment >3 days).

Results: Analysis included 7109 discharges of patients with aSAH undergoing endovascular coil embolization procedures from 2002 to 2011. Median time to coil embolization in all patients was 1 day; 10.1% of patients waited >3 days until treatment. In multivariate analysis, patients treated at safety-net hospitals were more likely to have a prolonged time to coil embolization (odds ratio = 1.32, P < 0.01) compared with patients treated at low-burden hospitals.

Conclusions: After controlling for patient and hospital factors, individuals with aSAH treated at safety-net hospitals from 2002 to 2011 were more likely to have a delay to endovascular coil embolization than individuals treated at non-safety-net hospitals. This disparity could affect patient outcomes.
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http://dx.doi.org/10.1016/j.wneu.2018.08.101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6252127PMC
December 2018

Multiple Intracranial Aneurysms from Coccidioidal Meningitis: Case Report Featuring Aneurysm Formation and Spontaneous Thrombosis with Literature Review.

World Neurosurg 2019 Jan 7;121:117-123. Epub 2018 Sep 7.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA.

Background: Coccidioidal meningitis can progress to vasculitis with aneurysm formation. Although aneurysmogenesis is rare, it carries exceptionally high mortality. Except in one instance, prior case reports have documented universally fatal consequences.

Case Description: A 26-year-old man developed disseminated coccidioidomycosis with formation of multiple aneurysms throughout the anterior intracranial vasculature bilaterally. This report is unique in that it chronicles the formation and subsequent spontaneous thrombosis of several aneurysms over a 4-week period. In total 10 aneurysms were documented in the same patient-the highest reported to date. The patient was eventually discharged from the hospital for what has heretofore been a universally fatal disease process. Neurologic examination and vascular imaging 1 month after discharge demonstrated stable findings.

Conclusions: Coccidioidal aneurysms carry a high mortality. The mainstay of therapy remains lifelong triazole antifungal therapy with the addition of liposomal amphotericin in cases of treatment failure. Steroid use is controversial but should be considered whenever there is vascular involvement. Although watchful waiting is reasonable in light of the possibility of spontaneous thrombosis with medical management, dynamic changes in aneurysm size or configuration should prompt timely endovascular or operative interventions.
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http://dx.doi.org/10.1016/j.wneu.2018.08.220DOI Listing
January 2019

Predictors of Surgical Site Infection After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

World Neurosurg 2018 Dec 25;120:e440-e452. Epub 2018 Aug 25.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Objective: Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout.

Methods: We used the 2010-2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout.

Results: We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout.

Conclusions: SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.
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http://dx.doi.org/10.1016/j.wneu.2018.08.102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563908PMC
December 2018

Transblepharo-Preseptal Modified Orbitozygomatic Craniotomy for Treatment of Ruptured Aneurysm: 3-Dimensional Operative Video.

World Neurosurg 2018 11 6;119:232. Epub 2018 Aug 6.

Neurorestoration Center, Keck School of Medicine, University of Southern California, Los Angeles, California, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. Electronic address:

Various supraorbital approaches to the anterior cranial fossa using a transciliary or supraciliary incision have been described. An orbitotomy is a valuable addition to the standard supraorbital keyhole approach offering an extended angle of exposure with minimal frontal lobe retraction. The transpalpebral approach is common in oculoplastic surgery and offers excellent cosmetic outcomes using the natural crease of the superior eyelid. This approach avoids risk of eyebrow alopecia and damage to the frontalis muscle or frontalis branches of the facial nerve. A transblepharo-preseptal or transpalpebral modified orbitozygomatic approach for the treatment of unruptured anterior circulation aneurysms has been reported. Our experience with this approach has been that it has potential to offer anterior skull base access and outcomes that are not inferior to traditional approaches for selected cases including ruptured anterior circulation aneurysms. Moreover, we believe this approach can provide excellent cosmetic results and could minimize surgical time and hospitalization stay. This 3-dimensional video presents the case of a 47-year-old female with sudden-onset headache and seizure (Video 1). She was found to have a subarachnoid hemorrhage resulting from rupture of a carotid terminus aneurysm. Considering the location and morphology of the aneurysm, as well as the patient's eyelid anatomy, clip ligation via a transblepharo-preseptal modified orbitozygomatic craniotomy was recommended. Aneurysm clipping was uneventful, and postoperative imaging showed complete occlusion. The patient was discharged neurologically intact.
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http://dx.doi.org/10.1016/j.wneu.2018.07.250DOI Listing
November 2018

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery.

Neurosurgery 2019 03;84(3):726-732

Department of Neurological Surgery, University of Southern California, Los Angeles, California.

Background: Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions.

Objective: To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery.

Methods: All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year.

Results: We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea).

Conclusion: After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.
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http://dx.doi.org/10.1093/neuros/nyy187DOI Listing
March 2019

Utilizing Light-field Imaging Technology in Neurosurgery.

Cureus 2018 Apr 10;10(4):e2459. Epub 2018 Apr 10.

Department of Neurosurgery, University of Southern California, Los Angeles, USA.

Traditional still cameras can only focus on a single plane for each image while rendering everything outside of that plane out of focus. However, new light-field imaging technology makes it possible to adjust the focus plane after an image has already been captured. This technology allows the viewer to interactively explore an image with objects and anatomy at varying depths and clearly focus on any feature of interest by selecting that location during post-capture viewing. These images with adjustable focus can serve as valuable educational tools for neurosurgical residents. We explore the utility of light-field cameras and review their strengths and limitations compared to other conventional types of imaging. The strength of light-field images is the adjustable focus, as opposed to the fixed-focus of traditional photography and video. A light-field image also is interactive by nature, as it requires the viewer to select the plane of focus and helps with visualizing the three-dimensional anatomy of an image. Limitations include the relatively low resolution of light-field images compared to traditional photography and video. Although light-field imaging is still in its infancy, there are several potential uses for the technology to complement traditional still photography and videography in neurosurgical education.
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http://dx.doi.org/10.7759/cureus.2459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5991932PMC
April 2018

Evaluation of C2 pedicle screw placement via the freehand technique by neurosurgical trainees.

J Neurosurg Spine 2018 Sep 8;29(3):235-240. Epub 2018 Jun 8.

OBJECTIVE Freehand placement of C2 instrumentation is technically challenging and has a learning curve due the unique anatomy of the region. This study evaluated the accuracy of C2 pedicle screws placed via the freehand technique by neurosurgical resident trainees. METHODS The authors retrospectively reviewed all patients treated at the LAC+USC Medical Center undergoing C2 pedicle screw placement in which the freehand technique was used over a 1-year period, from June 2016 to June 2017; all procedures were performed by neurosurgical residents. Measurements of C2 were obtained from preoperative CT scans, and breach rates were determined from coronal reconstructions on postoperative scans. Severity of breaches reflected the percentage of screw diameter beyond the cortical edge (I = < 25%; II = 26%-50%; III = 51%-75%; IV = 76%-100%). RESULTS Neurosurgical residents placed 40 C2 pedicle screws in 24 consecutively treated patients. All screws were placed by or under the guidance of Pham, who is a postgraduate year 7 (PGY-7) neurosurgical resident with attending staff privileges, with a PGY-2 to PGY-4 resident assistant. The authors found an average axial pedicle diameter of 5.8 mm, axial angle of 43.1°, sagittal angle of 23.0°, spinal canal diameter of 25.1 mm, and axial transverse foramen diameter of 5.9 mm. There were 17 screws placed by PGY-2 residents, 7 screws placed by PGY-4 residents, and 16 screws placed by the PGY-7 resident. The average screw length was 26.0 mm, with a screw diameter of 3.5 mm or 4.0 mm. There were 7 total breaches (17.5%), of which 4 were superior (10.0%) and 3 were lateral (7.5%). There were no medial breaches. The breaches were classified as grade I in 3 cases (42.9%), II in 3 cases (42.9%), III in 1 case (14.3%), and IV in no cases. There were 3 breaches that occurred via placement by a PGY-2 resident, 3 breaches by a PGY-4 resident, and 1 breach by the PGY-7 resident. There were no clinical sequelae due to these breaches. CONCLUSIONS Freehand placement of C2 pedicle screws can be done safely by neurosurgical residents in early training. When breaches occurred, they tended to be superior in location and related to screw length choice, and no breaches were found to be clinically significant. Controlled exposure to this unique anatomy is especially pertinent in the era of work-hour restrictions.
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http://dx.doi.org/10.3171/2018.1.SPINE17875DOI Listing
September 2018

Occipital Artery to Posterior Cerebral Artery Bypass Using Descending Branch of the Lateral Circumflex Femoral Artery Graft for Treatment of Fusiform, Unruptured Posterior Cerebral Artery Aneurysm: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2018 Nov;15(5):E50-E51

Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Posterior cerebral artery (PCA) aneurysms can be technically challenging lesions due to the intricacy of perforating branches and the relationship to cranial nerves and the brainstem. Fusiform aneurysms of the perimesencephalic segment of the PCA are a rare finding which does not favor direct clip occlusion or reconstruction. In such cases, proximal parent vessel occlusion is an option for aneurysm treatment. Extracranial-intracranial (EC-IC) bypass can be used to revascularize beyond the lesion when considering proximal occlusion. Based on previous literature for occipital artery (OA) bypass and the time-consuming dissection required for OA harvest, an interposition graft was chosen. The descending branch of the lateral circumflex femoral artery (DLCFA) is a good alternative interposition graft with a diameter that is favorable for revascularizing smaller, more distal vessels.This 3-dimensional video presents the case of a 26-year-old female with severe headaches who was found to have unruptured, fusiform aneurysmal dilatations of the PCA. Given the patient's youth and the morphology of the aneurysms, an EC-IC bypass with proximal occlusion was recommended. The DLCFA was used as an interposition graft. The left OA was found to be a suitable donor. A subtemporal approach was used to access the PCA for proximal occlusion. An occipital interhemispheric approach was performed to isolate a suitable recipient segment of the ipsilateral PCA branch for microvascular end-to-side anastomosis. Postoperative catheter angiography showed significant thrombosis of the fusiform aneurysms and a patent EC-IC bypass. Postoperative magnetic resonance imaging showed no infarcts and the patient was discharged neurologically intact.The patient was consented for inclusion in a prospective institutional review board (IRB) approved database from which this IRB approved retrospective report was performed. The consent for intraoperative video and picture use was also obtained.Images in the video between 0:49 and 1:11, © University of Southern California Neurorestoration Center. Used with permission, all rights reserved.
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http://dx.doi.org/10.1093/ons/opy057DOI Listing
November 2018

Factors associated with burnout among US neurosurgery residents: a nationwide survey.

J Neurosurg 2018 11;129(5):1349-1363

10Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.

OBJECTIVEExcessive dissatisfaction and stress among physicians can precipitate burnout, which results in diminished productivity, quality of care, and patient satisfaction and treatment adherence. Given the multiplicity of its harms and detriments to workforce retention and in light of the growing physician shortage, burnout has garnered much attention in recent years. Using a national survey, the authors formally evaluated burnout among neurosurgery trainees.METHODSAn 86-item questionnaire was disseminated to residents in the American Association of Neurological Surgeons database between June and November 2015. Questions evaluated personal and workplace stressors, mentorship, career satisfaction, and burnout. Burnout was assessed using the previously validated Maslach Burnout Inventory. Factors associated with burnout were determined using univariate and multivariate logistic regression.RESULTSThe response rate with completed surveys was 21% (346/1643). The majority of residents were male (78%), 26-35 years old (92%), in a stable relationship (70%), and without children (73%). Respondents were equally distributed across all residency years. Eighty-one percent of residents were satisfied with their career choice, although 41% had at some point given serious thought to quitting. The overall burnout rate was 67%. In the multivariate analysis, notable factors associated with burnout included inadequate operating room exposure (OR 7.57, p = 0.011), hostile faculty (OR 4.07, p = 0.008), and social stressors outside of work (OR 4.52, p = 0.008). Meaningful mentorship was protective against burnout in the multivariate regression models (OR 0.338, p = 0.031).CONCLUSIONSRates of burnout and career satisfaction are paradoxically high among neurosurgery trainees. While several factors were predictive of burnout, including inadequate operative exposure and social stressors, meaningful mentorship proved to be protective against burnout. The documented negative effects of burnout on patient care and health care economics necessitate further studies for potential solutions to curb its rise.
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http://dx.doi.org/10.3171/2017.9.JNS17996DOI Listing
November 2018
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