Publications by authors named "James S Harrop"

225 Publications

The Impact of Incorporating Evidence-based Guidelines for Lumbar Fusion Surgery in Neurosurgical Resident Education.

World Neurosurg 2021 Jul 19. Epub 2021 Jul 19.

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania.

Background: Instrumented fusion procedures are essential in the treatment of degenerative lumbar spine disease to alleviate pain and improve neurologic function, but are being performed with increasing incidence and variability.

Objective: We implemented a training module for neurosurgery residents that is based on evidence-based criteria for lumbar fusion surgery and measured its effectiveness in the residents' decision making regarding whether patients should or should not undergo instrumented fusion.

Methods: The study design is a pretest versus posttest experiment conducted from September 2019 until July 2020 to measure improvement after formalized instruction on evidence-based guidelines. Neurosurgery resident physicians of all training levels at our institution participated and a test was administered at the beginning of each academic year. The highest possible score was 18 points in each pretest and posttest.

Results: The participation rate is 79.2% (19/24). There was a general trend of test score improvement across all levels of training with a greater degree of change for those with a lower compared to higher pretest scores, indicating a possible ceiling effect. Paired t-test demonstrated an overall mean score increase of 2 points (p<0.0001), equivalent to an 11.11%-increase (p<0.0001). Stratified by training group, the mean absolute change in test score was 2 (p=0.0217), 1.67 (p=0.0108), and 2.25 (p=0.0173) points for the junior, midlevel, and senior training groups, respectively.

Conclusions: The authors demonstrate that incorporating a targeted evidence-based learning module for lumbar spine fusion surgery can improve neurosurgery residents' clinical decision-making toward a more uniform practice supported by published data.
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http://dx.doi.org/10.1016/j.wneu.2021.07.045DOI Listing
July 2021

Impact of inhalational anesthetic agents on the baseline monitorability of motor evoked potentials (MEPs) during spine surgery: A review of 22,755 cervical and lumbar procedures.

Spine J 2021 Jul 15. Epub 2021 Jul 15.

SpecialtyCare, Brentwood, TN.

Background Context: During spine surgery, motor evoked potentials (MEPs) are often utilized to monitor both spinal cord function and spinal nerve root or plexus function. While there are reports evaluating the impact of anesthesia on the reliability of MEPs to monitor spinal cord function, less is known about the impact of anesthetics on the ability of MEPs to monitor spinal nerve root and plexus function.

Purpose: To compare the baseline monitorability and amplitude of MEPs during cervical and lumbar procedures between two cohorts based on the maintenance anesthetic regimen: a total intravenous anesthesia (TIVA) versus a regimen balanced with volatile inhalational and intravenous agents.

Study Design/setting: Baseline MEP data from a total of 16,559 cervical and 6,196 lumbar extradural spine procedures utilizing multimodality intraoperative neuromonitoring (IONM) including MEPs between January 2017 and March 2020 were obtained from a multi-institutional database. Two cohorts for each region of spine surgery were delineated based on the anesthetic regimen: a TIVA cohort and a Balanced anesthesia cohort.

Patient Sample: Age 18 and older OUTCOME MEASURES: Percent monitorability and amplitudes of baseline MEPs.

Methods: The baseline monitorability of each muscle MEP was evaluated by the IONM team in real-time and recorded in the patient's electronic medical record. The relation between anesthetic regimen and baseline monitorability was estimated using mixed effects logistic regression, with distinct models for cervical and lumbar procedures. Subsets of cervical and lumbar procedures from each anesthesia cohort in which all MEPs were deemed monitorable were randomly selected and the average peak-to-trough amplitude of each muscle MEP was retrospectively measured. Mixed-effects linear regression models were estimated (one each for cervical and lumbar procedures) to assess possible differences in average amplitude associated with anesthesia regimen.

Results: At the time of surgery, baseline MEPs were reported monitorable from all targeted muscles in 86.8% and 83.0% of cervical and lumbar procedures, respectively, for the TIVA cohort, but were reported monitorable in just 59.3% and 61.0% of cervical and lumbar procedures, respectively, in the Balanced cohort, yielding disparities of 27.5% and 22.0%, respectively. The model-adjusted monitorability disparity between cohorts for a given muscle MEP ranged from 0.2% -16.6% but was smallest for distal intrinsic hand and foot muscle MEPs (0.2%-1.1%) and was largest for proximal muscle MEPs (deltoid: 10.8%, biceps brachii: 8.8%, triceps: 13.0%, quadriceps: 16.6%, gastrocnemius: 7.8%, and tibialis anterior: 3.7%) where the monitorability was significantly decreased in the Balanced cohort relative to the TIVA cohort (P < 0.0001). Relative to the TIVA cohort, the model-adjusted amplitude of an MEP in the Balanced cohort was smaller for all muscles measured, ranging from 27.5%-78.0% smaller. Relative to the TIVA cohort, the model-adjusted amplitude of an MEP was significantly decreased (P <0.01) in the Balanced cohort for the most proximal muscles (Percent smaller: deltoid: 74.3%, biceps: 78.0%, triceps: 54.9.0%, quadriceps: 54.8%).

Conclusions: TIVA is the preferred anesthetic regimen for optimizing MEP monitoring during spine surgery. Inhalational agents significantly decrease MEP monitorability and amplitudes for most muscles, and this effect is especially pronounced for proximal limb muscles such as the deltoid, biceps, triceps, and quadriceps.
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http://dx.doi.org/10.1016/j.spinee.2021.07.002DOI Listing
July 2021

Are Lumbar Fusion Guidelines Followed? A Survey of North American Spine Surgeons.

Neurospine 2021 Jun 30;18(2):389-396. Epub 2021 Jun 30.

Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.

Objective: To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America.

Methods: An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics.

Results: A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01).

Conclusion: This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.
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http://dx.doi.org/10.14245/ns.2142136.068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8255757PMC
June 2021

Cervical fusion for treatment of degenerative conditions: Development of appropriate use criteria.

Spine J 2021 Jun 1. Epub 2021 Jun 1.

Department of Neurosurgery, Lahey Hospital & Medical Center, 41 Mall Road Charles A, Tufts University School of Medicine, Burlington, MA 01805-0105, USA.

Background Context: High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking.

Purpose: Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine.

Study Design/setting: Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations.

Outcome Measures: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters.

Methods: Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed.

Results: Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance.

Conclusions: Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate."
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http://dx.doi.org/10.1016/j.spinee.2021.05.023DOI Listing
June 2021

Longitudinal Impact of Acute Spinal Cord Injury on Clinical Pharmacokinetics of Riluzole, a Potential Neuroprotective Agent.

J Clin Pharmacol 2021 Apr 28. Epub 2021 Apr 28.

Department of Neurosurgery, Houston Methodist Research Institute, Houston, Texas, USA.

Riluzole, a benzothiazole sodium channel blocker that received US Food and Drug Administration approval to attenuate neurodegeneration in amyotrophic lateral sclerosis in 1995, was found to be safe and potentially efficacious in a spinal cord injury (SCI) population, as evident in a phase I clinical trial. The acute and progressive nature of traumatic SCI and the complexity of secondary injury processes can alter the pharmacokinetics of therapeutics. A 1-compartment with first-order elimination population pharmacokinetic model for riluzole incorporating time-dependent clearance and volume of distribution was developed from combined data of the phase 1 and the ongoing phase 2/3 trials. This change in therapeutic exposure may lead to a biased estimate of the exposure-response relationship when evaluating therapeutic effects. With the developed model, a rational, optimal dosing scheme can be designed with time-dependent modification that preserves the required therapeutic exposure of riluzole.
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http://dx.doi.org/10.1002/jcph.1876DOI Listing
April 2021

Achieving Value in Spine Surgery: 10 Major Cost Contributors.

Global Spine J 2021 Apr;11(1_suppl):14S-22S

Department of Neurological Surgery, 6559Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Narrative Review.

Objectives: The increasing cost of healthcare overall and for spine surgery, coupled with the growing burden of spine-related disease and rising demand have necessitated a shift in practice standards with a new emphasis on value-based care. Despite multiple attempts to reconcile the discrepancy between national recommendations for appropriate use and the patterns of use employed in clinical practice, resources continue to be overused-often in the absence of any demonstrable clinical benefit. The following discussion illustrates 10 areas for further research and quality improvement.

Methods: We present a narrative review of the literature regarding 10 features in spine surgery which are characterized by substantial disproportionate costs and minimal-if any-clear benefit. Discussion items were generated from a service-wide poll; topics mentioned with great frequency or emphasis were considered. Items are not listed in hierarchical order, nor is the list comprehensive.

Results: We describe the cost and clinical data for the following 10 items: Over-referral, Over-imaging & Overdiagnosis; Advanced Imaging for Low Back Pain; Advanced imaging for C-Spine Clearance; Advanced Imaging for Other Spinal Trauma; Neuromonitoring for Cervical Spine; Neuromonitoring for Lumbar Spine/Single-Level Surgery; Bracing & Spinal Orthotics; Biologics; Robotic Assistance; Unnecessary perioperative testing.

Conclusions: In the pursuit of value in spine surgery we must define what quality is, and what costs we are willing to pay for each theoretical unit of quality. We illustrate 10 areas for future research and quality improvement initiatives, which are at present overpriced and underbeneficial.
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http://dx.doi.org/10.1177/2192568220971288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076814PMC
April 2021

Commentary on "A Prospective, Single-Blinded, Bicentric Study, and Literature Review to Assess the Need of C2-Ganglion Preservation - SAVIOUR's Criteria".

Authors:
James S Harrop

Neurospine 2021 Mar 31;18(1):96-97. Epub 2021 Mar 31.

Department of Neurological and Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

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http://dx.doi.org/10.14245/ns.2142238.119DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021823PMC
March 2021

Overview of Traumatic Brain Injury in American Football Athletes.

Clin J Sport Med 2021 Mar 24. Epub 2021 Mar 24.

Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Rothman Sports Concussion Institute, Rothman Institute, Philadelphia, Pennsylvania; and Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania.

Objective: The aim of this review is to provide a summary of the epidemiology, clinical presentation, pathophysiology, and treatment of traumatic brain injury in collision athletes, particularly those participating in American football.

Data Sources: A literature search was conducted using the PubMed/MEDLINE and Google Scholar databases for publications between 1990 and 2019. The following search phrases were used: "concussion," "professional athletes," "collision athletes," "mild traumatic brain injury," "severe traumatic brain injury," "management of concussion," "management of severe traumatic brain injury," and "chronic traumatic encephalopathy." Publications that did not present epidemiology, clinical presentation, pathophysiology, radiological evaluation, or management were omitted. Classic articles as per senior author recommendations were retrieved through reference review.

Results: The results of the literature review yielded 147 references: 21 articles discussing epidemiology, 16 discussing clinical presentation, 34 discussing etiology and pathophysiology, 10 discussing radiological evaluation, 34 articles for on-field management, and 32 articles for medical and surgical management.

Conclusion: Traumatic brain injuries are frequent in professional collision athletes, and more severe injuries can have devastating and lasting consequences. Although sport-related concussions are well studied in professional American football, there is limited literature on the epidemiology and management of severe traumatic brain injuries. This article reviews the epidemiology, as well as the current practices in sideline evaluation, acute management, and surgical treatment of concussions and severe traumatic brain injury in professional collision athletes. Return-to-play decisions should be based on individual patient symptoms and recovery.
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http://dx.doi.org/10.1097/JSM.0000000000000918DOI Listing
March 2021

Intradural extramedullary capillary hemangioma of the cauda equina: case report of a rare spinal tumor.

Spinal Cord Ser Cases 2021 Mar 19;7(1):21. Epub 2021 Mar 19.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Introduction: Intradural extramedullary capillary hemangiomas of the cauda equina are exceedingly rare, with only 20 previous cases reported. In the adult population, these tumors are rare and can arise in the central and peripheral nervous systems from the dura or spinal nerve roots. Intradural capillary hemangiomas of the cauda equina can yield symptoms such as lower extremity weakness, pain, and bladder and bowel dysfunction. The clinical symptomology and surgical management of this rare spinal lesion are reviewed in this case report.

Case Presentation: A 50-year-old male presented with progressive bilateral lower extremity weakness for 2 years, with recent bladder and bowel dysfunction. On physical exam, strength was symmetrically impaired in both lower extremities. Pre-operative magnetic resonance imaging (MRI) of the lumbar spine demonstrated a gadolinium-enhanced intradural lesion at the L4 level. Laminectomy was performed and the lesion was resected. Histopathological analysis determined that the tumor demonstrated features consistent with a capillary hemangioma.

Discussion: Clinically, patients with capillary hemangiomas of the cauda equina present with space-occupying compressive deficits, including progressive low back and lower extremity pain, motor deficits, paresthesias, sensory loss, and bowel and bladder dysfunction. Acute presentation can transpire following a hemorrhagic episode, although this is more associated with cavernous rather than capillary hemangiomas. Our patient demonstrated non-acute, progressive weakness, and late-onset bladder and bowel dysfunction. This report demonstrates that this rare lesion should be included in the differential diagnosis of cauda equina lesions.
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http://dx.doi.org/10.1038/s41394-021-00383-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7979701PMC
March 2021

Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial.

JAMA 2021 03;325(10):942-951

Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio.

Importance: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results.

Objective: To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year.

Design, Setting, And Participants: Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020.

Interventions: Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion.

Main Outcomes And Measures: The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score.

Results: Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%).

Conclusions And Relevance: Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach.

Trial Registration: ClinicalTrials.gov Identifier: NCT02076113.
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http://dx.doi.org/10.1001/jama.2021.1233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944378PMC
March 2021

A Randomized Controlled Trial of Local Delivery of a Rho Inhibitor (VX-210) in Patients with Acute Traumatic Cervical Spinal Cord Injury.

J Neurotrauma 2021 Mar 1. Epub 2021 Mar 1.

BioAxone BioSciences, Inc, Boston, Massachusetts, USA.

Acute traumatic spinal cord injury (SCI) can result in severe, lifelong neurological deficits. After SCI, Rho activation contributes to collapse of axonal growth cones, failure of axonal regeneration, and neuronal loss. This randomized, double-blind, placebo-controlled phase 2b/3 study evaluated the efficacy and safety of Rho inhibitor VX-210 (9 mg) in patients after acute traumatic cervical SCI. The study enrolled patients 14-75 years of age with acute traumatic cervical SCIs, C4-C7 (motor level) on each side, and American Spinal Injury Association Impairment Scale (AIS) Grade A or B who had spinal decompression/stabilization surgery commencing within 72 h after injury. Patients were randomized 1:1 with stratification by age (<30 vs. ≥30 years) and AIS grade (A vs. B with sacral pinprick preservation vs. B without sacral pinprick preservation). A single dose of VX-210 or placebo in fibrin sealant was administered topically onto the dura over the site of injury during decompression/stabilization surgery. Patients were evaluated for medical, neurological, and functional changes, and serum was collected for pharmacokinetics and immunological analyses. Patients were followed up for up to 12 months after treatment. A planned interim efficacy-based futility analysis was conducted after ∼33% of patients were enrolled. The pre-defined futility stopping rule was met, and the study was therefore ended prematurely. In the final analysis, the primary efficacy end-point was not met, with no statistically significant difference in change from baseline in upper-extremity motor score at 6 months after treatment between the VX-210 (9-mg) and placebo groups. This work opens the door to further improvements in the design and conduct of clinical trials in acute SCI.
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http://dx.doi.org/10.1089/neu.2020.7096DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8309435PMC
March 2021

A study of probable benefit of a bioresorbable polymer scaffold for safety and neurological recovery in patients with complete thoracic spinal cord injury: 6-month results from the INSPIRE study.

J Neurosurg Spine 2021 Feb 5:1-10. Epub 2021 Feb 5.

7InVivo Therapeutics Corp., Cambridge, Massachusetts.

Objective: The aim of this study was to evaluate whether the investigational Neuro-Spinal Scaffold (NSS), a highly porous bioresorbable polymer device, demonstrates probable benefit for safety and neurological recovery in patients with complete (AIS grade A) T2-12 spinal cord injury (SCI) when implanted ≤ 96 hours postinjury.

Methods: This was a prospective, open-label, multicenter, single-arm study in patients with a visible contusion on MRI. The NSS was implanted into the epicenter of the postirrigation intramedullary spinal cord contusion cavity with the intention of providing structural support to the injured spinal cord parenchyma. The primary efficacy endpoint was the proportion of patients who had an improvement of ≥ 1 AIS grade (i.e., conversion from complete paraplegia to incomplete paraplegia) at the 6-month follow-up visit. A preset objective performance criterion established for the study was defined as an AIS grade conversion rate of ≥ 25%. Secondary endpoints included change in neurological level of injury (NLI). This analysis reports on data through 6-month follow-up assessments.

Results: Nineteen patients underwent NSS implantation. There were 3 early withdrawals due to death, which were all determined by investigators to be unrelated to the NSS or the implantation procedure. Seven of 16 patients (43.8%) who completed the 6-month follow-up visit had conversion of neurological status (AIS grade A to grade B [n = 5] or C [n = 2]). Five patients showed improvement in NLI of 1 to 2 levels compared with preimplantation assessment, 3 patients showed no change, and 8 patients showed deterioration of 1 to 4 levels. There were no unanticipated or serious adverse device effects or serious adverse events related to the NSS or the implantation procedure as determined by investigators.

Conclusions: In this first-in-human study, implantation of the NSS within the spinal cord appeared to be safe in the setting of surgical decompression and stabilization for complete (AIS grade A) thoracic SCI. It was associated with a 6-month AIS grade conversion rate that exceeded historical controls. The INSPIRE study data demonstrate that the potential benefits of the NSS outweigh the risks in this patient population and support further clinical investigation in a randomized controlled trial.Clinical trial registration no.: NCT02138110 (clinicaltrials.gov).
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http://dx.doi.org/10.3171/2020.8.SPINE191507DOI Listing
February 2021

Spinal ganglion cyst presenting with radiculopathy: diagnostic challenges and differential.

Spinal Cord Ser Cases 2021 Jan 19;7(1). Epub 2021 Jan 19.

Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA.

Introduction: Ganglion cysts are benign soft tissue lesions, usually arising from periarticular connective tissue. These are very rarely reported in the spine, but when seen can cause radiculopathy or myelopathy.

Case Presentation: A 68-year-old female patient presented with worsening radiculopathy and right foot drop and imaging noted a right L5-S1 foraminal mass. The lesion was gross totally resected. Histological analysis revealed myxoid degeneration and inflammation, without a synovial lining, consistent with ganglion cyst.

Discussion: While uncommon, intra-foraminal ganglion cysts can be distinguished from synovial cysts through imaging and histology and are typically amenable to surgical resection. Greater knowledge and insight about differentiating ganglion versus synovial cyst may prevent resection of facet joints and prevent a fusion procedure.
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http://dx.doi.org/10.1038/s41394-020-00373-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815751PMC
January 2021

The influence of timing of surgical decompression for acute spinal cord injury: a pooled analysis of individual patient data.

Lancet Neurol 2021 02 21;20(2):117-126. Epub 2020 Dec 21.

Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada. Electronic address:

Background: Although there is a strong biological rationale for early decompression of the injured spinal cord, the influence of the timing of surgical decompression for acute spinal cord injury (SCI) remains debated, with substantial variability in clinical practice. We aimed to objectively evaluate the effect of timing of decompressive surgery for acute SCI on long-term neurological outcomes.

Methods: We did a pooled analysis of individual patient data derived from four independent, prospective, multicentre data sources, including data from December, 1991, to March, 2017. Three of these studies had been published; of these, only one study previously specifically analysed the effect of the timing of surgical decompression. These four datasets were selected because they were among the highest quality acute SCI datasets available and contained highly granular data. Individual patient data were obtained by request from study authors. All patients who underwent decompressive surgery for acute SCI within these datasets were included. Patients were stratified into early (<24 h after spinal injury) and late (≥24 h after spinal injury) decompression groups. Neurological outcomes were assessed by American Spinal Injury Association (ASIA), or International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), examination. The primary endpoint was change in total motor score from baseline to 1 year after spinal injury. Secondary endpoints were ASIA Impairment Scale (AIS) grade and change in upper-extremity motor, lower-extremity motor, light touch, and pin prick scores after 1 year. One-stage meta-analyses were done by hierarchical mixed-effects regression adjusting for baseline score, age, mechanism of injury, AIS grade, level of injury, and administration of methylprednisolone. Effect sizes were summarised by mean difference (MD) for sensorimotor scores and common odds ratio (cOR) for AIS grade, with corresponding 95% CIs. As a secondary analysis, change in total motor score was regressed against time to surgical decompression (h) as a continuous variable, using a restricted cubic spline with adjustment for the same covariates as in the primary analysis.

Findings: We identified 1548 eligible patients from the four datasets. Outcome data at 1 year after spinal injury were available for 1031 patients (66·6%). Patients who underwent early surgical decompression (n=528) experienced greater recovery than patients who had late decompression surgery (n=1020) at 1 year after spinal injury; total motor scores improved by 23·7 points (95% CI 19·2-28·2) in the early surgery group versus 19·7 points (15·3-24·0) in the late surgery group (MD 4·0 points [1·7-6·3]; p=0·0006), light touch scores improved by 19·0 points (15·1-23·0) vs 14·8 points (11·2-18·4; MD 4·3 [1·6-7·0]; p=0·0021), and pin prick scores improved by 18·3 points (13·7-22·9) versus 14·2 points (9·8-18·6; MD 4·0 [1·5-6·6]; p=0·0020). Patients who had early decompression also had better AIS grades at 1 year after surgery, indicating less severe impairment, compared with patients who had late surgery (cOR 1·48 [95% CI 1·16-1·89]; p=0·0019). When time to surgical decompression was modelled as a continuous variable, there was a steep decline in change in total motor score with increasing time during the first 24-36 h after injury (p<0·0001); and after 36 h, change in total motor score plateaued.

Interpretation: Surgical decompression within 24 h of acute SCI is associated with improved sensorimotor recovery. The first 24-36 h after injury appears to represent a crucial time window to achieve optimal neurological recovery with decompressive surgery following acute SCI.

Funding: None.
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http://dx.doi.org/10.1016/S1474-4422(20)30406-3DOI Listing
February 2021

Safety and efficacy of riluzole in patients undergoing decompressive surgery for degenerative cervical myelopathy (CSM-Protect): a multicentre, double-blind, placebo-controlled, randomised, phase 3 trial.

Lancet Neurol 2021 02 22;20(2):98-106. Epub 2020 Dec 22.

Department of Health Services, University of Washington, Seattle, WA, USA.

Background: Degenerative cervical myelopathy represents the most common form of non-traumatic spinal cord injury. This trial investigated whether riluzole enhances outcomes in patients undergoing decompression surgery for degenerative cervical myelopathy.

Methods: This multicentre, double-blind, placebo-controlled, randomised, phase 3 trial was done at 16 university-affiliated centres in Canada and the USA. Patients with moderate-to-severe degenerative cervical myelopathy aged 18-80 years, who had a modified Japanese Orthopaedic Association (mJOA) score of 8-14, were eligible. Patients were randomly assigned (1:1) to receive either oral riluzole (50 mg twice a day for 14 days before surgery and then for 28 days after surgery) or placebo. Randomisation was done using permuted blocks stratified by study site. Patients, physicians, and outcome assessors remained masked to treatment group allocation. The primary endpoint was change in mJOA score from baseline to 6 months in the intention-to-treat (ITT) population, defined as all individuals who underwent randomisation and surgical decompression. Adverse events were analysed in the modified intention-to-treat (mITT) population, defined as all patients who underwent randomisation, including those who did not ultimately undergo surgical decompression. This study is registered with ClinicalTrials.gov, NCT01257828.

Findings: From Jan 31, 2012, to May 16, 2017, 408 patients were screened. Of those screened, 300 were eligible (mITT population); 290 patients underwent decompression surgery (ITT population) and received either riluzole (n=141) or placebo (n=149). There was no difference between the riluzole and placebo groups in the primary endpoint of change in mJOA score at 6-month follow-up: 2·45 points (95% CI 2·08 to 2·82 points) versus 2·83 points (2·47 to 3·19), difference -0·38 points (-0·90 to 0·13; p=0·14). The most common adverse events were neck or arm or shoulder pain, arm paraesthesia, dysphagia, and worsening of myelopathy. There were 43 serious adverse events in 33 (22%) of 147 patients in the riluzole group and 34 serious adverse events in 29 (19%) of 153 patients in the placebo group. The most frequent severe adverse events were osteoarthrosis of non-spinal joints, worsening of myelopathy, and wound complications.

Interpretation: In this trial, adjuvant treatment for 6 weeks perioperatively with riluzole did not improve functional recovery beyond decompressive surgery in patients with moderate-to-severe degenerative cervical myelopathy. Whether riluzole has other benefits in this patient population merits further study.

Funding: AOSpine North America.
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http://dx.doi.org/10.1016/S1474-4422(20)30407-5DOI Listing
February 2021

Development of a Telemedicine Neurological Examination for Spine Surgery: A Pilot Trial.

Clin Spine Surg 2020 11;33(9):355-369

Department of Orthopaedic Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University Hospital.

Study Design: This was a prospective cohort study.

Objective: The objective of this study was to design and test a novel spine neurological examination adapted for telemedicine.

Summary Of Background Data: Telemedicine is a rapidly evolving technology associated with numerous potential benefits for health care, especially in the modern era of value-based care. To date, no studies have assessed whether.

Methods: Twenty-one healthy controls and 20 patients with cervical or lumbar spinal disease (D) were prospectively enrolled. Each patient underwent a telemedicine neurological examination as well as a traditional in-person neurological examination administered by a fellowship trained spine surgeon and a physiatrist. Both the telemedicine and in-person tests consisted of motor, sensory, and special test components. Scores were compared via univariate analysis and secondary qualitative outcomes, including responses from a satisfaction survey, were obtained upon completion of the trial.

Results: Of the 20 patients in the D group, 9 patients had cervical disease and 11 patients had lumbar disease. Comparing healthy control with the D group, there were no significant differences with respect to all motor scores, most sensory scores, and all special tests. There was a high rate of satisfaction among the cohort with 92.7% of participants feeling "very satisfied" with the overall experience.

Conclusions: This study presents the development of a viable neurological spine examination adapted for telemedicine. The findings in this study suggest that patients have comparable motor, sensory, and special test scores with telemedicine as with a traditional in-person examination administered by an experienced clinician, as well as reporting a high rate of satisfaction among participants. To our knowledge, this is the first telemedicine neurological examination for spine surgery. Further studies are warranted to validate these findings.
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http://dx.doi.org/10.1097/BSD.0000000000001066DOI Listing
November 2020

Developing standardized titles to classify the adverse events in 7,418 cranial and spinal neurosurgical procedures.

Clin Neurol Neurosurg 2020 11 1;198:106121. Epub 2020 Aug 1.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA. Electronic address:

Background: Neurosurgical procedures are life- and function-saving but carry a risk of adverse events (AE) which can cause permanent neurologic deficits. Unfortunately, there is lack of clearly defined AEs associated with given procedures, and their reporting is non-uniform and often arbitrary. However, with an increasing number of neurosurgical procedures performed, there is a need for standardization of AEs for systematic tracking. Such a system would establish a baseline for future quality improvement strategies.

Objective: To review our institutional AEs and devise standardized titles specific to the spine, tumor, functional, and vascular neurosurgery divisions.

Methods: A review of prospective monthly-reported morbidity and mortality (M&M) conference data within the Department of Neurological Surgery was conducted from January 2017 to December 2019. An AE was defined as any mortality, an "unintended and undesirable diagnostic or therapeutic event", "an event that prolongs the patient's hospital stay", or an outcome with permanent or transient neurologic deficit.

Results: A total of 1096 AEs from 7418 total procedures (14.8 %) were identified. Of those, 418 (5.6 %) were in cerebrovascular, 249 (3.4 %) were in neuro-oncology and 429 (5.8 %) were in the spine & functional divisions. The most common AEs across all divisions were infection (17 %), hemorrhage (11 %) and cerebrospinal fluid (CSF) leak (7.8 %). Other AEs were indirectly related to the neurosurgical procedure, such as deep vein thrombosis or pulmonary embolism (2.7 %), or pneumothorax (0.3 %).

Conclusion: This work illustrates standardized AEs can be implemented universally across the spectrum of neurological surgery. Standardization can help identify recurring AE patterns through better tracking.
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http://dx.doi.org/10.1016/j.clineuro.2020.106121DOI Listing
November 2020

Therapeutic Impact of Traction Release After C5 Nerve Root Motor Evoked Potential (MEP) Alerts in Cervical Spine Surgery.

Clin Spine Surg 2020 12;33(10):E442-E447

Medical Department, SpecialtyCare, Brentwood, TN.

Study Design: A retrospective review of 40,919 cervical spine surgeries monitored with motor evoked potentials (MEPs) from a multi-institutional intraoperative neuromonitoring database.

Objective: The objective of this study was to determine the clinical impact of interventions prompted by C5 spinal nerve root MEP alerts.

Summary Of Background Data: MEPs have been shown to diagnose acute C5 palsies, but additional data are needed regarding the clinical impact of interventions in response to C5 MEP alerts.

Materials And Methods: Procedures with isolated C5 MEP alerts were categorized as fully resolved, partially resolved, or unresolved based on the status of signals at closure. Clinical outcomes were based on neurological assessment in the immediate postoperative period. The sensitivity, specificity, likelihood ratios, and odds ratios (ORs) of C5 MEP alerts for acute C5 palsies were calculated.

Results: The odds of an acute C5 palsy greatly increased if there was a C5 MEP alert [OR=340.9; 95% confidence (CI): 173.0, 671.6; P<0.0001], and increased further if the alert persisted through closure (OR=820.8; 95% CI: 398.1, 1692.0; P<0.0001). Relative to procedures with unresolved C5 MEP alerts, the risk of an acute C5 palsy significantly decreased if a C5 MEP alert was fully resolved by closure (OR=0.07; 95% CI: 0.02, 0.25; P<0.0001). For alerts resolved during positioning or exposure, 90.9% were resolved with the release of positional traction, and for resolved alerts that occurred after exposure, 36.3% involved just traction release, 14.1% involved both traction release and surgical action, and 30.3% involved just surgical action. The sensitivity of C5 MEP alerts for acute C5 palsies was anesthetic dependent: 89.7% (26/29) in the total intravenous regimen cohort but just 50.0% (10/20) in the inhalational anesthesia cohort.

Conclusions: The timely release of positional traction is an effective intervention for resolving C5 MEP alerts and reducing the odds of an acute postoperative C5 palsy. Surgical maneuvers, such as the release of distraction or graft adjustment, should be attempted in conjunction with traction release depending on the surgical context of the alert.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BSD.0000000000000969DOI Listing
December 2020

The Use of Magnetic Resonance Imaging by Spine Surgeons in Management of Spinal Trauma Across AO Regions-Results of AO Spine Survey.

World Neurosurg 2020 05 4;137:e389-e394. Epub 2020 Feb 4.

Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA. Electronic address:

Objective: To determine use of magnetic resonance imaging (MRI) for management of spinal trauma as a function of the availability of an MRI scanner across AO regions.

Methods: A survey regarding MRI availability and/or accessibility was conducted across 6 global AO regions. Questions were formulated to 1) evaluate availability of an MRI scanner and 2) whether the availability of an MRI scanner influenced time taken to image patients with spinal trauma. Pairwise comparison of responses among AO regions was performed.

Results: The survey was sent to 5.813 AO Spine members and 561 completed surveys were obtained (Africa, 3%; Asia Pacific, 22.1%; Europe, 30.8%; Latin America, 25.7%; Middle East, 9.4%; and North America, 8.9%). On availability of MRI for spinal trauma, 31.9% reported that MRI was readily available at all times, 51.3% noted 24-hour availability, but more difficult to obtain during nighttime, and 8.7% reported not having an MRI at their hospital. On time taken to obtain scans if MRI is readily available, 32.4% responded that imaging was obtained within 1 hour, whereas 39.9% stated between 1 and 4 hours. On time taken to obtain scans when MRI is least available, 7% responded that imaging was completed within 1 hour whereas 31.4% stated between 1 and 4 hours. Responses from Latin America significantly differed (P < 0.05) from all other AO regions except Africa.

Conclusions: MRI use varies across AO regions, with clinical decision making on obtaining MRI in spinal trauma being influenced heavily by the availability of an MRI scanner.
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http://dx.doi.org/10.1016/j.wneu.2020.01.200DOI Listing
May 2020

Early Surgery for Traumatic Spinal Cord Injury: Where Are We Now?

Global Spine J 2020 Jan 6;10(1 Suppl):84S-91S. Epub 2020 Jan 6.

Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Narrative review.

Objective: There is a strong biological rationale to perform early decompression after traumatic spinal cord injury (SCI). With an enlarging clinical evidence base, most spine surgeons internationally now favor early decompression for the majority of SCI patients; however, a number of pertinent questions remain surrounding this therapy.

Methods: A narrative review evaluating the status of early surgery for SCI. In particular, we addressed the following questions: (1) Which patients stand to benefit most from early surgery? 2) What is the most appropriate time threshold defining early surgery?

Results: Although heterogeneity exists, the evidence generally seems to support early surgery. While the best evidence exists for cervical SCI, there is insufficient data to support a differential effect for early surgery depending on neurological level or injury severity. When comparing thresholds to define early versus late surgery-including a later threshold (48-72 hours), an earlier threshold (24 hours), and an ultra-early threshold (8-12 hours)-the 2 earlier time points seem to be associated with the greatest potential for improved outcomes. However, existing prehospital and hospital logistics pose barriers to early surgery in a significant proportion of patients. An overview of recommendations from the recent AOSpine guidelines is provided.

Conclusion: In spite of increasing acceptance of early surgery post SCI, further research is needed to (1) identify subgroups of patients who stand to derive particular benefit-in particular to develop more evidence-based approaches for central cord syndrome and (2) investigate the efficacy and feasibility of ultra-early surgery targeting more aggressive timelines.
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http://dx.doi.org/10.1177/2192568219877860DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947677PMC
January 2020

Minimizing Blood Loss in Spine Surgery.

Global Spine J 2020 Jan 6;10(1 Suppl):71S-83S. Epub 2020 Jan 6.

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

Study Design: Broad narrative review.

Objective: To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery.

Methods: A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery.

Results: There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements.

Conclusion: As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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http://dx.doi.org/10.1177/2192568219868475DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947684PMC
January 2020

Implementation of a Spine-Centered Care Pathway at a Regional Academic Spine Center.

Global Spine J 2020 Jan 6;10(1 Suppl):36S-40S. Epub 2020 Jan 6.

Thomas Jefferson University, Philadelphia, PA, USA.

Study Design: Retrospective case series.

Objective: To describe the early implementation of an inpatient spinal surgery unit and measure the impact on cost and length of stay (LOS).

Methods: A retrospective case review was performed for frequent spine-related diagnosis-related groups (DRGs) cared for by a dedicated multidisciplinary team: combined anterior/posterior (AP) spinal fusion with major complicating or comorbid condition (MCC), combined (AP) spinal fusion with CC, combined (AP) spinal fusion without complicating or comorbid (CC)/MCC, cervical spinal fusion with MCC, cervical spinal fusion with CC, and cervical spinal fusion without CC/MCC. Four time periods were compared: historical control, initial pathway implementation, full pathway implementation, and spine unit opening. Mean hospital LOS, mean and median total costs (USD), and ratio of costs-to-charges were analyzed.

Results: The number of spine cases per interim ranged from 219 to 258. The mean overall hospital LOS and mean cost varied from 3.8 to 4.3 days for all DRGs across the time periods and was not significant. Cost also did not vary significantly throughout. Median variable cost per anterior/posterior spinal fusion procedure with a CC or MCC declined by 16 311, first with the institution of a spine pathway protocol by USD8738 and then USD7423 with the establishment of a spine care unit but did not reach significance.

Conclusions: The use of a standardized, inpatient spine care pathway implemented by a multidisciplinary team may reduce the hospital length of stay and decrease overall costs.
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http://dx.doi.org/10.1177/2192568219856354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6947681PMC
January 2020

Brief History of Spinal Neurosurgical Societies in the United States: Part 1.

Neurospine 2019 Dec 31;16(4):631-636. Epub 2019 Dec 31.

Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, FL, USA.

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http://dx.doi.org/10.14245/ns.1938378.189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944983PMC
December 2019

Usefulness of Timed Up and Go (TUG) Test for Prediction of Adverse Outcomes in Patients Undergoing Thoracolumbar Spine Surgery.

Neurosurgery 2020 03;86(3):E273-E280

Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: Spine surgery rates have increased and the high postoperative morbidity in these patients result in increased costs. Consequently, it is essential to identify patients at risk of adverse outcomes.

Objective: To assess whether preoperative Timed Up and Go (TUG) test performance can predict high-grade postoperative complications.

Methods: A prospective cohort study of patients undergoing elective thoracolumbar spine surgery in a tertiary care hospital between 2017 and 2018. Patients were assessed preoperatively and assigned to the slow-TUG group if unable to perform or test performance time was ≥18.4 s. Primary outcome: high-grade postoperative complications. Secondary outcomes: overall complications, length of stay (LOS), discharge to healthcare facility, readmission and emergency department (ED) presentation. Patients were followed-up until 6 wk after surgery.

Results: One hundred three patients (mean age 62.95 ± 10.97 yr) were enrolled. Slow-TUG group were more likely to be classified as American Society of Anaesthesiology (ASA) class 3 (74.1% vs 47.4%, P = .02), non-independent (25.9% vs 5.3%, P < .01), and frail (92.3% vs 42.1%, P < .01). TUG was an independent predictor of high-grade complications (adjusted odds ratio (OR): 4.97, 95% CI: 1.18-22.47), overall complications (OR: 3.77, 95% CI: 1.33-11.81), discharge to a skilled-nursing facility (OR: 3.2, 95% CI: 1.00-10.70), readmission within 6 wk of surgery (OR: 9.14, 95% CI: 2.39-41.26) and LOS (adjusted incident rate ratio (IRR): 1.45, 95% CI: 1.16-1.80).

Conclusion: Compared to traditional risk factors, TUG is an important predictor of adverse postoperative outcomes and may be used preoperatively to identify high-risk thoracolumbar surgery patients.
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http://dx.doi.org/10.1093/neuros/nyz480DOI Listing
March 2020

Epstein-Barr Virus-Associated Smooth Muscle Tumor of the Spine After Bone Marrow Transplant: Case Report and Review of Literature.

World Neurosurg 2020 Mar 3;135:192-196. Epub 2019 Dec 3.

Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA. Electronic address:

Background: Epstein-Barr virus-associated smooth muscle tumors (SMTs) are rare neoplasms that have been found to develop in immunocompromised patients. Three distinct groups of affected patients have been described: (1) human immunodeficiency virus-infected patients, (2) post-transplant patients, and (3) patients with congenital immunodeficiency. The tumors can develop anywhere in the body, with 17 reported cases occurring in the spinal canal, all in patients with human immunodeficiency virus infection.

Case Description: We report the first case of Epstein-Barr virus-associated SMT affecting the spinal canal in a post-bone marrow transplant adult patient. Interestingly, unlike other reported cases, the patient described here had not been receiving immunosuppressive therapy in the 2 years prior to diagnosis of the tumor.

Conclusions: Despite the growing number of case reports, this diagnosis presents a challenge, as the pathophysiology and optimal treatment regimens are not well understood. Results of a literature review of Epstein-Barr virus-associated SMT of the spine as well as a discussion of the presentation, management, and prognosis of this condition is presented here.
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http://dx.doi.org/10.1016/j.wneu.2019.11.160DOI Listing
March 2020

Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients.

BMJ Open 2019 10 10;9(10):e031486. Epub 2019 Oct 10.

Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK

Objectives: To establish the recovery priorities of individuals suffering with degenerative cervical myelopathy (DCM).

Design: A cross-sectional, observational study.

Setting: Patients from across the world with a diagnosis of DCM accessed the survey over an 18-month period on Myelopathy.org, an international myelopathy charity.

Participants: 481 individuals suffering from DCM completed the online survey fully.

Main Outcome Measures: Functional recovery domains were established through qualitative interviews and a consensus process. Individuals were asked about their disease characteristics, including limb pain (Visual Analogue Scale) and functional disability (patient-derived version of the modified Japanese Orthopaedic Association score). Individuals ranked recovery domains (arm and hand function, walking, upper body/trunk function, sexual function, elimination of pain, sensation and bladder/bowel function) in order of priority. Priorities were analysed as the modal first priority and mean ranking. The influence of demographics on selection was analysed, with significance <0.05.

Results: Of 659 survey responses obtained, 481 were complete. Overall, pain was the most popular recovery priority (39.9%) of respondents, followed by walking (20.2%), sensation (11.9%) and arm and hand function (11.5%). Sexual function (5.7%), bladder and bowel (3.7%) and trunk function (3.5%) were chosen less frequently. When considering the average ranking of symptoms, while pain remained the priority (2.6±2.0), this was closely followed by walking (2.9±1.7) and arm/hand function (3.0±1.4). Sensation ranked lower (4.3±2.1). With respect to disease characteristics, overall pain remained the recovery priority, with the exception of patients with greater walking impairment (<0.005) who prioritised walking, even among patients with lower pain scores.

Conclusions: This is the first study investigating patient priorities in DCM. The patient priorities reported provide an important framework for future research and will help to ensure that it is aligned with patient needs.
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http://dx.doi.org/10.1136/bmjopen-2019-031486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797315PMC
October 2019

Utility of motor evoked potentials to diagnose and reduce lower extremity motor nerve root injuries during 4,386 extradural posterior lumbosacral spine procedures.

Spine J 2020 02 31;20(2):191-198. Epub 2019 Aug 31.

SpecialtyCare, Brentwood, TN, USA.

Background Context: Motor evoked potentials (MEPs) have excellent sensitivity for monitoring the functional integrity of the lateral corticospinal tract of the spinal cord. The sensitivity for nerve root function, however, is not as well established; consequently, MEPs are often not utilized for posterior extradural spine procedures distal to the conus. Spontaneous electromyography (sEMG) and somatosensory evoked potentials (SSEPs) are often included for these procedures, but their limited sensitivity has been well documented. Given the risk of motor nerve root injuries during spine procedures, and specifically increased vulnerability of the L4 and L5 nerves, the sensitivity of MEPs was evaluated for diagnostic accuracy and therapeutic impact.

Purpose: To determine the diagnostic sensitivity of MEPs during lumbosacral spine procedures and the potential therapeutic impact of the resolution of MEP alerts.

Study Design: A total of 4,386 posterior extradural lumbosacral spine procedures utilizing multimodality intraoperative neuromonitoring (IONM) with sEMG, SSEPs, and MEPs were abstracted from a multi-institutional database. All cases took place between October 2015 and October 2017. No external funding was provided.

Outcome Measures: Sensitivity and specificity, as well as positive and negative likelihood ratios for new postoperative neurologic deficits were calculated for each modality individually as well as when combined (multimodality).

Patient Sample: Age 18 and older METHODS: Data entered in the electronic medical record were analyzed. Alerts to sEMG activity, decreases in SSEP amplitude, or decreases in MEP amplitude were documented as well as the status of the alerts at closure: resolved or unresolved. The presence of an sEMG alert or an unresolved MEP or SSEP alert at closure was considered a positive diagnostic result, and these results were assessed relative to presence of new immediate onset neurologic deficits as documented in the electronic record.

Results: The sensitivity and specificity of multimodality IONM for new immediate-onset lower extremity motor deficits were 100.0% (95% confidence interval: [64.6, 100.0]) and 92.2% (91.1, 93.1), respectively. Looking at the modalities in isolation, the sensitivity of MEPs was considerably better than either lower extremity sEMG or posterior tibial nerve SSEPs: 100.0% (78.5, 100.0) versus just 14.3% (4.0, 39.9) and 28.6% (8.2, 64.1), respectively. Surprisingly, the specificity of lower extremity MEPs was better than sEMG, 97.9% (97.5, 98.3) versus 95.4% (94.7, 96.0) (χ=43.0, p<.001). The specificity of lower extremity SSEPs was 99.0% (98.5, 99.3). Only 4.4% of all procedures had a lower extremity MEP alert. There were 14 significant new nerve root injuries and all 14 had unresolved MEPs at closure. Total 85.7% of those nerve root injuries were dorsiflexion foot drop injuries and all had unresolved tibialis anterior MEP alerts. Although the overall rate of nerve root injuries was 0.32% (14/4,386), the rate for procedures with unresolved isolated tibialis anterior MEP alerts was 44.4% (12/27). The therapeutic impact is evident in the 2.0% of cases (87/4,386) with lower extremity MEP alerts that were able to be fully resolved by closure and for which the rate of injury was zero.

Conclusions: The diagnostic accuracy of MEPs for anterior tibialis-related nerve root dysfunction supports the inclusion of this modality during routine posterior extradural lumbosacral procedures, especially when the L4 or L5 nerve roots are at risk. Moreover, therapeutic interventions that lead to the resolution of MEP alerts avert postoperative neurologic injuries.
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http://dx.doi.org/10.1016/j.spinee.2019.08.013DOI Listing
February 2020

Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury.

Crit Care Med 2019 11;47(11):e854-e862

Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada.

Objectives: There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome.

Design: Multicenter prospective registry.

Setting: Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network.

Patients: Eight-hundred one spinal cord injury patients enrolled by participating centers.

Interventions: Appropriate spinal cord injury treatment at individual centers.

Measurements And Main Results: A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores.

Conclusions: Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.
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http://dx.doi.org/10.1097/CCM.0000000000003937DOI Listing
November 2019

Trauma.

Oper Neurosurg (Hagerstown) 2019 Aug;17(Suppl 2):S45-S75

Department of Neurosurgery, Northwell Health, Manhasset, New York.

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http://dx.doi.org/10.1093/ons/opz089DOI Listing
August 2019
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