Publications by authors named "Leslie C Robinson"

12 Publications

  • Page 1 of 1

Crossing the Cervicothoracic Junction During Posterior Cervical Fusion for Myelopathy Is Associated With Superior Radiographic Parameters But Similar Clinical Outcomes.

Neurosurgery 2020 10;87(5):1016-1024

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.

Background: For laminectomy and posterior spinal fusion (LPSF) surgery for cervical spondylotic myelopathy (CSM), the evidence is unclear as to whether fusions should cross the cervicothoracic junction (CTJ).

Objective: To compare LPSF outcomes between those with and without lower instrumented vertebrae (LIV) crossing the CTJ.

Methods: A consecutive series of adults undergoing LPSF for CSM from 2012 to 2018 with a minimum of 12-mo follow-up were identified. LPSF with subaxial upper instrumented vertebrae and LIV between C6 and T2 were included. Clinical and radiographic outcomes were compared.

Results: A total of 79 patients were included: 46 crossed the CTJ (crossed-CTJ) and 33 did not. The mean follow-up was 22.2 mo (minimum: 12 mo). Crossed-CTJ had higher preoperative C2-7 sagittal vertical axis (cSVA) (33.3 ± 16.0 vs 23.8 ± 12.4 mm, P = .01) but similar preoperative cervical lordosis (CL) and CL minus T1-slope (CL minus T1-slope) (P > .05, both comparisons). The overall reoperation rate was 3.8% (crossed-CTJ: 2.2% vs not-crossed: 6.1%, P = .37). In adjusted analyses, crossed-CTJ was associated with superior cSVA (β = -9.7; P = .002), CL (β = 6.2; P = .04), and CL minus T1-slope (β = -6.6; P = .04), but longer operative times (β = 46.3; P = .001). Crossed- and not-crossed CTJ achieved similar postoperative patient-reported outcomes [Visual Analog Scale (VAS) neck pain, VAS arm pain, Nurick Grade, Modified Japanese Orthopedic Association Scale, Neck Disability Index, and EuroQol-5D] in adjusted multivariable analyses (adjusted P > .05). For the entire cohort, higher postoperative CL was associated with lower postoperative arm pain (adjusted Pearson's r -0.1, P = .02). No postoperative cervical radiographic parameters were associated with neck pain (P > .05).

Conclusion: Subaxial LPSF for CSM that crossed the CTJ were associated with superior radiographic outcomes for cSVA, CL, and CL minus T1-slope, but longer operative times. There were no differences in neck pain or reoperation rate.
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http://dx.doi.org/10.1093/neuros/nyaa241DOI Listing
October 2020

Perioperative Anesthesia Lean Implementation Is Associated With Increased Operative Efficiency in Posterior Cervical Surgeries at a HighVolume Spine Center.

Neurospine 2020 Jun 5;17(2):390-397. Epub 2020 Feb 5.

Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA.

Objective: Lean management strategies aim to increase efficiency by eliminating waste or by improving processes to optimize value. The operating room (OR) is an arena where these strategies can be implemented. We assessed changes in OR efficiency after the application of lean methodology on perioperative anesthesia associated with posterior cervical spine surgeries.

Methods: We utilized pre- and post-lean study design to identify inefficiencies during the perioperative anesthesia process and implemented strategies to improve the process. Patient characteristics were recorded to assess for differences between the 2 groups (group 1, prelean; group 2, post-lean). In the pre-lean period, key steps in the perioperative anesthesia process were identified that were amenable to lean implementation. The time required for each identified key step was recorded by an independent study coordinator. The times for each step were then compared between the groups utilizing univariate analyses.

Results: After lean implementation, there was a significant decrease in overall perioperative anesthesia process time (88.4 ± 4.7 minutes vs. 76.2 ± 3.2 minutes, p = 0.04). This was driven by significant decreases in the steps: transport and setup (10.4 ± 0.8 minutes vs. 8.0 ± 0.7 minutes, p = 0.03) and positioning (20.8 ± 2.1 minutes vs. 15.7 ± 1.3 minutes, p = 0.046). Of note, the total time spent in the OR was lower for group 2 (270.1 ± 14.6 minutes vs. 252.8 ± 14.1 minutes) but the result was not statistically significant, even when adjusting for number of operated levels.

Conclusion: Lean methodology may be successfully applied to posterior cervical spine surgery whereby improvements in the perioperative anesthetic process are associated with significantly increased OR efficiency.
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http://dx.doi.org/10.14245/ns.1938318.159DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7338954PMC
June 2020

The MISDEF2 algorithm: an updated algorithm for patient selection in minimally invasive deformity surgery.

J Neurosurg Spine 2019 Oct;32(2):221-228

11Department of Neurosurgery, Cornell Medical Center, New York, New York.

Objective: Minimally invasive surgery (MIS) can be used as an alternative or adjunct to traditional open techniques for the treatment of patients with adult spinal deformity. Recent advances in MIS techniques, including advanced anterior approaches, have increased the range of candidates for MIS deformity surgery. The minimally invasive spinal deformity surgery (MISDEF2) algorithm was created to provide an updated framework for decision-making when considering MIS techniques in correction of adult spinal deformity.

Methods: A modified algorithm was developed that incorporates a patient's preoperative radiographic parameters and leads to one of 4 general plans ranging from basic to advanced MIS techniques to open deformity surgery with osteotomies. The authors surveyed 14 fellowship-trained spine surgeons experienced with spinal deformity surgery to validate the algorithm using a set of 24 cases to establish interobserver reliability. They then re-surveyed the same surgeons 2 months later with the same cases presented in a different sequence to establish intraobserver reliability. Responses were collected and analyzed. Correlation values were determined using SPSS software.

Results: Over a 3-month period, 14 fellowship-trained deformity surgeons completed the surveys. Responses for MISDEF2 algorithm case review demonstrated an interobserver kappa of 0.85 for the first round of surveys and an interobserver kappa of 0.82 for the second round of surveys, consistent with substantial agreement. In at least 7 cases, there was perfect agreement between the reviewing surgeons. The mean intraobserver kappa for the 2 surveys was 0.8.

Conclusions: The MISDEF2 algorithm was found to have substantial inter- and intraobserver agreement. The MISDEF2 algorithm incorporates recent advances in MIS surgery. The use of the MISDEF2 algorithm provides reliable guidance for surgeons who are considering either an MIS or an open approach for the treatment of patients with adult spinal deformity.
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http://dx.doi.org/10.3171/2019.7.SPINE181104DOI Listing
October 2019

Sexual Dysfunction: Prevalence and Prognosis in Patients Operated for Degenerative Lumbar Spondylolisthesis.

Neurosurgery 2020 08;87(2):200-210

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.

Background: There is a paucity of investigation on the impact of spondylolisthesis surgery on back pain-related sexual inactivity.

Objective: To investigate predictors of improved sex life postoperatively by utilizing the prospective Quality Outcomes Database (QOD) registry.

Methods: A total of 218 patients who underwent surgery for grade 1 degenerative lumbar spondylolisthesis were included who were sexually active. Sex life was assessed by Oswestry Disability Index item 8 at baseline and 24-mo follow-up.

Results: Mean age was 58.0 ± 11.0 yr, and 108 (49.5%) patients were women. At baseline, 178 patients (81.7%) had sex life impairment. At 24 mo, 130 patients (73.0% of the 178 impaired) had an improved sex life. Those with improved sex lives noted higher satisfaction with surgery (84.5% vs 64.6% would undergo surgery again, P = .002). In multivariate analyses, lower body mass index (BMI) was associated with improved sex life (OR = 1.14; 95% CI [1.05-1.20]; P < .001). In the younger patients (age < 57 yr), lower BMI remained the sole significant predictor of improvement (OR = 1.12; 95% CI [1.03-1.23]; P = .01). In the older patients (age ≥ 57 yr)-in addition to lower BMI (OR = 1.12; 95% CI [1.02-1.27]; P = .02)-lower American Society of Anesthesiologists (ASA) grades (1 or 2) (OR = 3.7; 95% CI [1.2-12.0]; P = .02) and ≥4 yr of college education (OR = 3.9; 95% CI [1.2-15.1]; P = .03) were predictive of improvement.

Conclusion: Over 80% of patients who present for surgery for degenerative lumbar spondylolisthesis report a negative effect of the disease on sex life. However, most patients (73%) report improvement postoperatively. Sex life improvement was associated with greater satisfaction with surgery. Lower BMI was predictive of improved sex life. In older patients-in addition to lower BMI-lower ASA grade and higher education were predictive of improvement.
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http://dx.doi.org/10.1093/neuros/nyz406DOI Listing
August 2020

Summary of Guidelines for the Treatment of Lumbar Spondylolisthesis.

Neurosurg Clin N Am 2019 Jul;30(3):353-364

Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue M779, San Francisco, CA 94143, USA.

Degenerative lumbar spondylolisthesis is a common cause of low back pain, affecting about 11.5% of the United States population. Patients with symptomatic lumbar spondylolisthesis may first be treated with conservative management strategies including, but not limited to, non-narcotic and narcotic pain medications, epidural steroid injections, transforaminal injections, and physical therapy. For well-selected patients who fail conservative management strategies, surgical management is appropriate. This article summarizes the guidelines for the treatment of lumbar spondylolisthesis.
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http://dx.doi.org/10.1016/j.nec.2019.02.009DOI Listing
July 2019

A novel technique for awake, minimally invasive transforaminal lumbar interbody fusion: technical note.

Neurosurg Focus 2019 04;46(4):E16

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is associated with improved patient-reported outcomes in well-selected patients. Recently, some neurosurgeons have aimed to further improve outcomes by utilizing multimodal methods to avoid the use of general anesthesia. Here, the authors report on the use of a novel awake technique for MI-TLIF in two patients. They describe the successful use of liposomal bupivacaine in combination with a spinal anesthetic to allow for operative analgesia.
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http://dx.doi.org/10.3171/2019.1.FOCUS18510DOI Listing
April 2019

Comparison of Fusion Rates Based on Graft Material Following Occipitocervical and Atlantoaxial Arthrodesis in Adults and Children.

Oper Neurosurg (Hagerstown) 2018 11;15(5):530-537

Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado.

Background: Fusion rates following rigid internal instrumentation for occipitocervical and atlantoaxial instability approach 100% in many reports. Based on this success and the morbidity that can be associated with obtaining autograft for fusion, surgeons increasingly select alternative graft materials.

Objective: To examine fusion failure using various graft materials in a retrospective observational study.

Methods: Insurance claims databases (Truven Health MarketScan® [Truven Health Analytics, Ann Arbor, Michigan] and IMS Health Lifelink/PHARMetrics [IMS Health, Danbury, Connecticut]) were used to identify patients with CPT codes 22590 and 22595. Patients were divided by age (≥18 yr = adult) and arthrodesis code, establishing 4 populations. Each population was further separated by graft code: group 1 = 20938 (structural autograft); group 2 = 20931 (structural allograft); group 3 = other graft code (nonstructural); group 4 = no graft code. Fusion failure was assigned when ≥1 predetermined codes presented in the record ≥90 d following the last surgical procedure.

Results: Of 522 patients identified, 419 were adult and 103 were pediatric. Fusion failure occurred in 10.9% (57/522) of the population. There was no statistically significant difference in fusion failure based on graft material. Fusion failure occurred in 18.9% of pediatric occipitocervical fusions, but in 9.2% to 11.1% in the other groups.

Conclusion: Administrative data regarding patients who underwent instrumented occipitocervical or atlantoaxial arthrodesis do not demonstrate differences in fusion rates based on the graft material selected. When compared to many contemporary primary datasets, fusion failure was more frequent; however, several recent studies have shown higher failure rates than previously reported. This may be influenced by broad patient selection and fusion failure criteria that were selected in order to maximize the generalizability of the findings.
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http://dx.doi.org/10.1093/ons/opy013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6186910PMC
November 2018

Analysis and interrater reliability of pB-C2 using MRI and CT: data from the Park-Reeves Syringomyelia Research Consortium on behalf of the Pediatric Craniocervical Society.

J Neurosurg Pediatr 2017 Aug 19;20(2):170-175. Epub 2017 May 19.

Department of Neurosurgery, Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, New York.

OBJECTIVE The distance to the ventral dura, perpendicular to the basion to C2 line (pB-C2), is commonly employed as a measure describing the anatomy of the craniovertebral junction. However, both the reliability among observers and the clinical utility of this measurement in the context of Chiari malformation Type I (CM-I) have been incompletely determined. METHODS Data were reviewed from the first 600 patients enrolled in the Park-Reeves Syringomyelia Research Consortium with CM-I and syringomyelia. Thirty-one cases were identified in which both CT and MRI studies were available for review. Three pediatric neurosurgeons independently determined pB-C2 values using common imaging sequences: MRI (T1-weighted and T2-weighted with and without the inclusion of retro-odontoid soft tissue) and CT. Values were compared and intraclass correlations were calculated among imaging modalities and observers. RESULTS Intraclass correlation of pB-C2 demonstrated strong agreement between observers (intraclass correlation coefficient [ICC] range 0.72-0.76). Measurement using T2-weighted MRI with the inclusion of retro-odontoid soft tissue showed no significant difference with measurement using T1-weighted MRI. Measurements using CT or T2-weighted MRI without retro-odontoid soft tissue differed by 1.6 mm (4.69 and 3.09 mm, respectively, p < 0.05) and were significantly shorter than those using the other 2 sequences. Conclusions pB-C2 can be measured reliably by multiple observers in the context of pediatric CM-I with syringomeyelia. Measurement using T2-weighted MRI excluding retro-odontoid soft tissue closely approximates the value obtained using CT, which may allow for the less frequent use of CT in this patient population. Measurement using T2-weighted MRI including retro-odontoid soft tissue or using T1-weighted MRI yields a more complete assessment of the extent of ventral brainstem compression, but its association with clinical outcomes requires further study.
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http://dx.doi.org/10.3171/2017.3.PEDS16604DOI Listing
August 2017

Potential evolution of neurosurgical treatment paradigms for craniopharyngioma based on genomic and transcriptomic characteristics.

Neurosurg Focus 2016 Dec;41(6):E3

Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado; and.

The recent genomic and transcriptomic characterization of human craniopharyngiomas has provided important insights into the pathogenesis of these tumors and supports that these tumor types are distinct entities. Critically, the insights provided by these data offer the potential for the introduction of novel therapies and surgical treatment paradigms for these tumors, which are associated with high morbidity rates and morbid conditions. Mutations in the CTNNB1 gene are primary drivers of adamantinomatous craniopharyngioma (ACP) and lead to the accumulation of β-catenin protein in a subset of the nuclei within the neoplastic epithelium of these tumors. Dysregulation of epidermal growth factor receptor (EGFR) and of sonic hedgehog (SHH) signaling in ACP suggest that paracrine oncogenic mechanisms may underlie ACP growth and implicate these signaling pathways as potential targets for therapeutic intervention using directed therapies. Recent work shows that ACP cells have primary cilia, further supporting the potential importance of SHH signaling in the pathogenesis of these tumors. While further preclinical data are needed, directed therapies could defer, or replace, the need for radiation therapy and/or allow for less aggressive surgical interventions. Furthermore, the prospect for reliable control of cystic disease without the need for surgery now exists. Studies of papillary craniopharyngioma (PCP) are more clinically advanced than those for ACP. The vast majority of PCPs harbor the BRAF mutation. There are now 2 reports of patients with PCP that had dramatic therapeutic responses to targeted agents. Ongoing clinical and research studies promise to not only advance our understanding of these challenging tumors but to offer new approaches for patient management.
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http://dx.doi.org/10.3171/2016.9.FOCUS16308DOI Listing
December 2016

Minimally invasive percutaneous screw fixation of traumatic spondylolisthesis of the axis.

J Neurosurg Spine 2015 May 27;22(5):459-65. Epub 2015 Feb 27.

Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina.

OBJECT Most cases of traumatic spondylolisthesis of the axis (hangman's fracture) can be treated nonoperatively with reduction and subsequent immobilization in a rigid cervical collar or halo. However, in some instances, operative management is necessary and can be accomplished by using either anterior or posterior fusion techniques. Because open posterior procedures can result in significant blood loss, pain, and limited cervical range of motion, other less invasive options for posterior fixation are needed. The authors describe a minimally invasive, navigation-guided technique for surgical treatment of Levine-Edwards (L-E) Type II hangman's fractures. METHODS For 5 patients with L-E Type II hangman's fracture requiring operative reduction and internal fixation, percutaneous screw fixation directed through the fracture site was performed. This technique was facilitated by use of intraoperative 3D fluoroscopy and neuronavigation. RESULTS Of the 5 patients, 2 were women, 3 were men, and age range was 46-67 years. No intraoperative or postoperative complications occurred. All patients wore a rigid cervical collar, and flexion-extension radiographs were obtained at 6 months. For all patients, dynamic imaging demonstrated a stable construct. CONCLUSIONS L-E type II hangman's fractures can be safely repaired by using percutaneous minimally invasive surgical techniques. This technique may be appropriate, depending on circumstances, for all L-E Type I and II hangman's fractures; however, the degree of associated ligament injury and disc disruption must be accounted for. Percutaneous fixation is not appropriate for L-E Type III fractures because of significant displacement and ligament and disc disruption. This report is meant to serve as a feasibility study and is not meant to show superiority of this procedure over other surgical options.
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http://dx.doi.org/10.3171/2014.10.SPINE131168DOI Listing
May 2015

Relationship of vocal cord paralysis to the coil diameter of vagus nerve stimulator leads.

J Neurosurg 2015 Mar 19;122(3):532-5. Epub 2014 Dec 19.

Department of Neurosurgery, University of Colorado School of Medicine, Aurora;

Object: This investigation was done to examine, following implantation of vagus nerve stimulators, the relationship of vocal cord paralysis to the inner diameter of the coils used to attach the stimulator lead to the nerve.

Methods: All data in this investigation were collected, as mandated by the FDA, by the manufacturer of vagus nerve stimulators and were made available without restrictions for analysis by the authors. The data reflect all initial device implantations in the United States for the period from 1997 through 2012.

Results: Vocal cord paralysis was reported in 193 of 51,882 implantations. In patients aged 18 years and older, the incidence of paralysis was 0.26% when the stimulator leads had coil diameters of 3 mm and 0.51% when the leads had 2-mm-diameter coils (p < 0.05). Across all age groups, the incidence of vocal cord paralysis increased with age at implantation for leads having 2-mm-diameter coils.

Conclusions: In patients aged 18 years and older, vocal cord paralysis occurred at almost twice the rate with the implantation of vagus nerve stimulator leads having 2-mm-diameter coils than with leads having 3-mm-diameter coils. The incidence of vocal cord paralysis increases with patient age at implantation.
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http://dx.doi.org/10.3171/2014.10.JNS14640DOI Listing
March 2015

The effects of pharmacist interventions on patients with polypharmacy.

Pharm Pract (Granada) 2006 Jul;4(3):103-9

Department of Pharmacy Practice. College of Pharmacy. Medical University of South Carolina . Charleston, South Carolina ( USA ).

Polypharmacy, the state of being prescribed or taking more medications than clinically appropriate, can result in a variety of negative outcomes for both patients and healthcare facilities. These include negative outcomes such as adverse drug effects, hospitalizations, and poor patient health, as well as economic outcomes such as increased drug cost and costs associated with increased utilization of health services. Available data suggests pharmacists have the potential to have a large effect in combating this problem through a variety of interventions such as reducing the number of medications taken, reducing the number of doses taken, increasing patient adherence, preventing adverse drug reactions (ADRs), improving patient quality of life and decreasing facility and drug costs. A small number of studies have been performed on the pharmacists' role in addressing the problem of polypharmacy; however, they include various populations, settings, and measured outcomes. Furthermore, some of the results are conflicting. Nonetheless, this review of the available literature concludes that pharmacist interventions can improve patient outcomes. With the ever-increasing costs of healthcare, the substantial cost savings for patients as well as institutions provided by these interventions are further justification for widespread implementation of pharmacist interventions at healthcare institutions.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4156841PMC
July 2006
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