Publications by authors named "Luis Tumialan"

71 Publications

"Disruptive Technology" in Spine Surgery and Education: Virtual and Augmented Reality.

Oper Neurosurg (Hagerstown) 2021 Jun;21(Supplement_1):S85-S93

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

Background: Technological advancements are the drivers of modern-day spine care. With the growing pressure to deliver faster and better care, surgical-assist technology is needed to harness computing power and enable the surgeon to improve outcomes. Virtual reality (VR) and augmented reality (AR) represent the pinnacle of emerging technology, not only to deliver higher quality education through simulated care, but also to provide valuable intraoperative information to assist in more efficient and more precise surgeries.

Objective: To describe how the disruptive technologies of VR and AR interface in spine surgery and education.

Methods: We review the relevance of VR and AR technologies in spine care, and describe the feasibility and limitations of the technologies.

Results: We discuss potential future applications, and provide a case study demonstrating the feasibility of a VR program for neurosurgical spine education.

Conclusion: Initial experiences with VR and AR technologies demonstrate their applicability and ease of implementation. However, further prospective studies through multi-institutional and industry-academic partnerships are necessary to solidify the future of VR and AR in spine surgery education and clinical practice.
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http://dx.doi.org/10.1093/ons/opab114DOI Listing
June 2021

Identifying patients at risk for nonroutine discharge after surgery for cervical myelopathy: an analysis from the Quality Outcomes Database.

J Neurosurg Spine 2021 May 7:1-9. Epub 2021 May 7.

15Department of Neurological Surgery, University of Utah, Salt Lake City, Utah.

Objective: Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry.

Methods: The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics.

Results: Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38-5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00-4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17-4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0-11 vs moderate 12-14, OR 2, 95% CI 1.07-3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12-48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2-3 levels, OR 0.3, 95% CI 0.1-0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25-0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance).

Conclusions: The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.
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http://dx.doi.org/10.3171/2020.11.SPINE201442DOI Listing
May 2021

Dimensional Characterization of the Human Lumbar Interlaminar Space as a Guide for Safe Application of Minimally Invasive Dilators.

Oper Neurosurg (Hagerstown) 2021 Feb 13. Epub 2021 Feb 13.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

Background: The risk of interlaminar passage of a dilator into the lumbar spinal canal in minimally invasive approaches is currently unknown. Among anthropometric data reported in the medical literature, there is no cadaveric report of the interlaminar dimensions of the lumbar spine.

Objective: To report the lumbar interlaminar dimensions in neutral, flexion, and extension postures.

Methods: A total of 8 spines were sectioned into lumbar segments. Digitized coordinate data defining the locations and movements of chosen anatomic points on the laminar edges at a given spinal level were used to measure changes in the opening dimensions during static neutral posture and flexion-extension movements. Interlaminar dimensions were averaged and categorized for each vertebral level and spinal posture.

Results: The mean interlaminar distance increased from neutral posture to flexion across all vertebral levels. The mean interlaminar distances in the neutral posture ranged from 12.21 mm (L5-S1) to 14.88 mm (L1-L2). In flexion, the range was from 17.15 mm (L5-S1) to 18.50 mm (L4-L5). These measurements are greater than the first several diameters of dilators in all minimally invasive dilator sets.

Conclusion: The precise measurements of the lumbar interlaminar space are valuable to minimally invasive spine surgeons for the dilatation phase of the operation. The risk of interlaminar passage of a minimally invasive dilator is greatest in flexion with dilators that have a diameter of 16 mm or less. There is considerably less risk of interlaminar passage in patients positioned on an extended Jackson table.
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http://dx.doi.org/10.1093/ons/opab011DOI Listing
February 2021

Access to Neurosurgery in the Era of Narrowing Insurance Networks: Statewide Analysis of Patient Protection and Affordable Care Act Marketplace Plans in Arizona.

World Neurosurg 2021 May 28;149:e963-e968. Epub 2021 Jan 28.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address:

Objective: The Patient Protection and Affordable Care Act (ACA) sought to expand access to health care for 46 million uninsured Americans. Increasing consumer coverage and ensuring affordability of care have raised concerns about ACA Marketplace plans with limited in-network physician coverage (narrow network plans). We assessed the neurosurgery coverage of ACA Marketplace plans in Arizona.

Methods: The Health Insurance Marketplace website was used to identify ACA Marketplace plans in Arizona. Plan-specific details were examined to search for in-network neurosurgeons (2016-2019). Physician- and patient-level information was obtained using Intellimed health care databases, which provide specific neurosurgery diagnosis-related group information.

Results: Although 5 insurance providers offered plans on the ACA Marketplace in Arizona, only 1 plan was available in 13 of 15 counties (87%). Evaluation of in-network coverage found that all in-network outpatient neurosurgery providers are in 5 of 15 counties (33%). Most of the other counties (9 of 10) have neurosurgery facilities, but do not have in-network access to neurosurgical care within the county (∼1.1 million people or 15% of the state population).

Conclusions: By narrowing the network of providers, insurance companies are attempting to maintain fiscal viability of their ACA Marketplace products. However, 10 of the 15 counties (67%) in Arizona do not have access to outpatient neurosurgical care through these plans despite the presence of neurosurgical facilities in most counties. Access to neurosurgical care requires consideration of network coverage in policies designed to expand coverage and coverage options for patients insured through the ACA Marketplace.
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http://dx.doi.org/10.1016/j.wneu.2021.01.064DOI Listing
May 2021

Osteolysis after cervical disc arthroplasty.

Eur Spine J 2020 11 31;29(11):2723-2733. Epub 2020 Aug 31.

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

Purpose: Cervical disc arthroplasty (CDA) has become an increasingly popular treatment for cervical degenerative disc disease. One potential complication is osteolysis. However, current literature on this topic appears limited. The purpose of this study is to elucidate the incidence, aetiology, consequence, and subsequent treatment of this complication.

Methods: A systematic literature review was performed according to the PRISMA guidelines. Studies discussing the causes, incidence and management of osteolysis after a CA were included.

Results: A total of nine studies were included. We divided these studies into two groups: (1) large case series in which an active radiological evaluation for osteolysis was performed (total = six studies), (2) case report studies, which discussed symptomatic cases of osteolysis (total = three). The incidence of asymptomatic osteolysis ranged from 8 to 64%; however, only one study reported an incidence of < 10% and when this case was excluded the incidence ranged from 44 to 64%. Severe asymptomatic bone loss (exposure of the implant) was found in less than 4% of patients. Bone loss from osteolysis appeared to occur early (< 1 year) after surgery and late (> 1 year) as well. Symptomatic patients with osteolysis often required revision surgery. These patients required removal of implant and conversion to fusion in the majority of the cases.

Conclusions: Osteolysis after CDA is common; however, the majority of cases have only mild or asymptomatic presentations that do not require revision surgery. The timing of osteolysis varies significantly. This may be due to differences in the aetiology of osteolysis.
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http://dx.doi.org/10.1007/s00586-020-06578-2DOI Listing
November 2020

In Reply: Dimensional Characterization of the Human Cervical Interlaminar Space as a Guide for Safe Application of Minimally Invasive Dilators.

Authors:
Luis M Tumialán

Oper Neurosurg (Hagerstown) 2020 09;19(4):E464

Department of Neurosurgery Barrow Neurological Institute St. Joseph's Hospital and Medical Center Phoenix, Arizona.

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http://dx.doi.org/10.1093/ons/opaa205DOI Listing
September 2020

Commentary: A Comparison of Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Grade 1 Degenerative Lumbar Spondylolisthesis: An Analysis of the Prospective Quality Outcomes Database.

Authors:
Luis M Tumialán

Neurosurgery 2020 09;87(3):E306-E307

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

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http://dx.doi.org/10.1093/neuros/nyaa132DOI Listing
September 2020

Dimensional Characterization of the Human Cervical Interlaminar Space as a Guide for Safe Application of Minimally Invasive Dilators.

Oper Neurosurg (Hagerstown) 2020 09;19(3):E275-E282

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: The risk of interlaminar passage of a dilator into the cervical spinal canal in minimally invasive approaches is currently unknown. Among the various anthropometric data reported in the literature, there is no report of the interlaminar dimensions in the cervical spine.

Objective: To report the cervical interlaminar dimensions in neutral, flexion, and extension.

Methods: A total of 8 spines were sectioned into cervical (C2-T1) segments. Digitized coordinate data defining the locations and movements of chosen anatomic points on the laminar edges at a given spinal level were used to compute the dimensions during a static neutral posture, flexion, and extension positions to mimic the positions during surgery. Interlaminar dimensions were averaged and categorized for each vertebral level and spinal posture.

Results: Based on the reported measurements, the smallest diameter dilator in commonly used dilator sets has the potential to traverse the interlaminar space at all levels in flexion. In a neutral posture, the average interlaminar distance at C2-3, C6-7, and C7-T1 was still greater than 2.0 mm, the smallest diameter of the initial dilator. The largest interlaminar distance was at C6-7 in flexion (7.68 ± 1.60 mm).

Conclusion: Because dilators pass directly onto the cervical lamina without visualization of the midline structures, the interlaminar distances have increased relevance in the minimally invasive cervical approaches of foraminotomy and laminectomy. The data in this report demonstrate the theoretical risk of interlaminar passage with small diameter dilators in posterior minimally invasive approaches to the cervical spine.
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http://dx.doi.org/10.1093/ons/opaa013DOI Listing
September 2020

Surgeon and staff radiation exposure in minimally invasive spinal surgery: prospective series using a personal dosimeter.

J Neurosurg Spine 2020 Feb 7:1-7. Epub 2020 Feb 7.

1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Objective: The level of radiation awareness by surgeons and residents in spinal surgery does not match the ubiquity of fluoroscopy in operating rooms in the United States. The present method of monitoring radiation exposure may contribute to the current deficiency in radiation awareness. Current dosimeters involve a considerable lag from the time that the surgical team is exposed to radiation to the time that they are provided with that exposure data. The objective of the current study was to assess the feasibility of monitoring radiation exposure in operating room personnel during lateral transpsoas lumbar interbody fusion (LLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) procedures by using a wearable personal device with real-time feedback.

Methods: Operating room staff participating in minimally invasive surgical procedures under a single surgeon during a 6-month period were prospectively enrolled in this study. All radiation dose exposures were recorded for each member of the surgical team (surgeon, assistant surgeon, scrub nurse, and circulating nurse) using a personal dosimeter (DoseAware). Radiation doses were recorded in microsieverts (μSv). Comparisons between groups were made using ANOVA with the Tukey post hoc test and Student t-test.

Results: Thirty-nine patients underwent interbody fusions: 25 underwent LLIF procedures (14 LLIF alone, 11 LLIF with percutaneous screw placement [PSP]) and 14 underwent MI-TLIF. For each operative scenario per spinal level, the surgeon experienced significantly higher (p < 0.035) average radiation exposure (LLIF: 167.9 μSv, LLIF+PSP: 424.2 μSv, MI-TLIF: 397.9 μSv) than other members of the team, followed by the assistant surgeon (LLIF: 149.7 μSv, LLIF+PSP: 242.3 μSv, MI-TLIF: 274.9 μSv). The scrub nurse (LLIF: 15.4 μSv, LLIF+PSP: 125.7 μSv, MI-TLIF: 183.0 μSv) and circulating nurse (LLIF: 1.2 μSv, LLIF+PSP: 9.2 μSv, MI-TLIF: 102.3 μSv) experienced significantly lower exposures. Radiation exposure was not correlated with the patient's body mass index (p ≥ 0.233); however, it was positively correlated with increasing patient age (p ≤ 0.004).

Conclusions: Real-time monitoring of radiation exposure is currently feasible and shortens the time between exposure and the availability of information regarding that exposure. A shortened feedback loop that offers more reliable and immediate data would conceivably raise the level of concern for radiation exposure in spinal surgeries and could alter patterns of behavior, leading to decreased exposures. Further studies are ongoing to determine the effect of real-time dosimetry in spinal surgery.
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http://dx.doi.org/10.3171/2019.11.SPINE19448DOI Listing
February 2020

Commentary: Mini-Open Lateral Corpectomy for Thoracolumbar Junction Lesions.

Authors:
Luis M Tumialán

Oper Neurosurg (Hagerstown) 2020 06;18(6):E183

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

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http://dx.doi.org/10.1093/ons/opz376DOI Listing
June 2020

Kambin's triangle: definition and new classification schema.

J Neurosurg Spine 2019 Nov 29:1-9. Epub 2019 Nov 29.

3Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida.

Kambin's triangle is an anatomical corridor used to access critical structures in a variety of spinal procedures. It is considered a safe space because it is devoid of vascular and neural structures of importance. Nonetheless, there is currently significant variation in the literature regarding the exact dimensions and anatomical borders of Kambin's triangle. This confusion was originally caused by leaving the superior articular process (SAP) unassigned in the description of the working triangle, despite Kambin identifying that structure in his original report. The SAP is the most relevant structure to consider when accessing the transforaminal corridor. Leaving the SAP unassigned has led to an open-handed application of the term "Kambin's triangle." That single eponym currently has two potential meanings, one meaning for endoscopic surgeons working through a corridor in the intact spine and a second meaning for surgeons accessing the disc space after a complete or partial facetectomy. Nevertheless, an anatomical corridor should have one consistent definition to clearly communicate techniques and use of instrumentation performed through that space. As such, the authors propose a new surgically relevant classification of this corridor. Assigning the SAP a border requires adding another dimension to the triangle, thereby transforming it into a prism. The term "Kambin's prism" indicates the assignment of a border to all relevant anatomical structures, allowing for a uniform definition of the 3D space. From there, the classification scheme considers the expansion of the corridor and the extent of bone removal, with a particular focus on the SAP.
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http://dx.doi.org/10.3171/2019.8.SPINE181475DOI Listing
November 2019

Commentary: Essential Neurosurgery for Medical Students.

Authors:
Luis M Tumialán

Oper Neurosurg (Hagerstown) 2019 09;17(3):E137-E138

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

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http://dx.doi.org/10.1093/ons/opz191DOI Listing
September 2019

Future Studies and Directions for the Optimization of Outcomes for Lumbar Spondylolisthesis.

Authors:
Luis M Tumialán

Neurosurg Clin N Am 2019 Jul 19;30(3):373-381. Epub 2019 Apr 19.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA. Electronic address:

Randomized prospective studies show clear benefits for operative versus nonoperative management of symptomatic lumbar spondylolisthesis, but there is no universally accepted surgical treatment. This article presents options for surgical management of lumbar spondylolisthesis, reviews the clinical trials delineating the role and type of surgical intervention, and explores the directions of future investigations. The next decade will add further clarity to the surgical management of spondylolisthesis, not by randomized prospective trials, but by surgical registries. The power of "big data" offered by registries will likely become the vehicle best suited to amass data on current and novel therapies.
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http://dx.doi.org/10.1016/j.nec.2019.02.011DOI Listing
July 2019

Commentary: The Anatomy of Disvalued Codes: The 63047 and the 22633.

Neurosurgery 2019 02;84(2):E122-E126

Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio.

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http://dx.doi.org/10.1093/neuros/nyy535DOI Listing
February 2019

Cervical Template to Optimize the Plate-to-Disc Distance in Instrumented Anterior Cervical Discectomies and Fusions: Instrumentation Assessment.

Authors:
Luis M Tumialán

Oper Neurosurg (Hagerstown) 2019 07;17(1):43-51

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: An increased incidence of adjacent segment degeneration in the cervical spine has been associated with a plate-to-disc distance (PDD) of <5 mm.

Objective: To introduce a template to size, position, and secure a cervical plate and ensure a 5-mm minimum PDD.

Methods: A prospective observational study was performed on 50 consecutive patients who had single-level anterior cervical discectomy and fusion (ACDF) using a cervical template. The cervical template was secured into the interbody spacer and assessed for length, PDD, and adequate vertebral body coverage. Holes were drilled through the template, which was then removed for cervical plate placement. Postoperative radiographs were assessed for PDD to adjacent segments, the angle from the vertical axis of the spine, and distance from midline. Neck Disability Index and visual analog scale scores for the neck and arm were obtained preoperatively and at 30-d and 90-d follow-up.

Results: Fifty patients underwent single-level ACDFs. The mean angle from the long axis of the spine was 2.4 (0.0-4.4) degrees; mean distance from midline was 1.3 (0.0-2.8) mm; and mean distance from the plate ends to the adjacent segments above was 5.4 (4.6-6.2) mm, and below, 5.1 (4.3-5.8) mm.

Conclusion: A cervical template can reliably secure the midline and predetermine the size of the shortest cervical plate for adequately stabilizing the segment for arthrodesis. Use of a template standardizes the process of maximizing the PDD.
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http://dx.doi.org/10.1093/ons/opy279DOI Listing
July 2019

The History of and Controversy over Kambin's Triangle: A Historical Analysis of the Lumbar Transforaminal Corridor for Endoscopic and Surgical Approaches.

World Neurosurg 2019 Mar 9;123:402-408. Epub 2018 Nov 9.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

The transforaminal corridor in the lumbar spine allows access to the traversing and exiting nerve roots, the thecal sac, and the intervertebral disc space. Surgeons performing midline and minimally invasive approaches for lumbar interbody fusion access the disc space within the boundaries created by the exiting root of a segment and the traversing root after a complete facetectomy and removal of the pars interarticularis and lamina. Endoscopic surgeons and interventional pain management physicians approach the lumbar segment through a similar corridor, but with the bony anatomy intact. Although the boundaries of the corridor may seem the same, the angle of the trajectory and the bone work between the two differ. The overlap between these 2 distinct access corridors has led to an openhanded application of the term Kambin's triangle. Initially described for endoscopic approaches to the lumbar spine for microdiscectomy, this working triangle has been grafted into the transforaminal lumbar interbody fusion literature. Given the similarities between these corridors, it is understandable how the lines of this nomenclature have blurred. The result has been an interchangeable application of the term Kambin's triangle for a variety of procedures in the spine literature. The objective of the current work is to add clarity to the various lumbar transforaminal corridors. The term Kambin's triangle should be limited to percutaneous access to the disc space for endoscopic procedures in the intact spine and should not be applied to transforaminal lumbar interbody fusion after laminectomy and facetectomy. Instead, the term expanded transforaminal corridor should be applied.
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http://dx.doi.org/10.1016/j.wneu.2018.10.221DOI Listing
March 2019

Letter: It is Time for Federal Protection Against Surprise Medical Billing.

Neurosurgery 2019 01;84(1):E101-E102

Department of Neurosurgery Barrow Neurological Institute Phoenix, Arizona.

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http://dx.doi.org/10.1093/neuros/nyy496DOI Listing
January 2019

Decreasing Radiation Emission in Minimally Invasive Spine Surgery Using Ultra-Low-Radiation Imaging with Image Enhancement: A Prospective Cohort Study.

World Neurosurg 2019 Feb 1;122:e805-e811. Epub 2018 Nov 1.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Spine Group Arizona, HonorHealth, Greenbaum Surgical Specialty Hospital, Scottsdale, Arizona, USA. Electronic address:

Background: Visualization of the anatomy in minimally invasive surgery (MIS) of the spine is limited and dependent on radiographic imaging, leading to increased radiation exposure to patients and surgical staff. Ultra-low-radiation imaging (ULRI) with image enhancement is a novel technology that may reduce radiation in the operating room. The aim of this study was to compare radiation emission between standard-dose and ULRI fluoroscopy with image enhancement in patients undergoing MIS of the spine.

Methods: This study prospectively enrolled 60 consecutive patients who underwent lateral lumbar interbody fusion, lateral lumbar interbody fusion with percutaneous pedicle screws, or MIS transforaminal lumbar interbody fusion. Standard-dose fluoroscopy was used in 31 cases, and ULRI with image enhancement was used in 29 cases. All imaging emission and radiation doses were recorded.

Results: Radiation emission per level was significantly less with ULRI than with standard-dose fluoroscopy for lateral lumbar interbody fusion (36.4 mGy vs. 119.8 mGy, P < 0.001), per screw placed in lateral lumbar interbody fusion (15.4 mGy per screw vs. 47.1 mGy per screw, P < 0.001), and MIS transforaminal lumbar interbody fusion (24.4 mGy vs. 121.6 mGy, P = 0.003). These differences represented reductions in radiation emission of 69.6%, 67.3%, and 79.9%. Total radiation doses per case were also significantly decreased for the transpsoas approach by 68.8%, lateral lumbar interbody fusion with percutaneous pedicle screws by 65.8%, and MIS transforaminal lumbar interbody fusion by 81.0% (P ≤ 0.004).

Conclusions: ULRI with image enhancement has the capacity to significantly decrease radiation emission in minimally invasive procedures without compromising visualization of anatomy or procedure safety.
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http://dx.doi.org/10.1016/j.wneu.2018.10.150DOI Listing
February 2019

Rate of Return to Military Active Duty After Single and 2-Level Anterior Cervical Discectomy and Fusion: A 4-Year Retrospective Review.

Neurosurgery 2019 07;85(1):96-104

Department of Neurosurgery, Balboa Naval Medical Center, San Diego, California.

Background: Over the years of rigorous of military service, military personnel may experience cervical spondylosis and radiculopathy. Given the frequency of this occurrence, the capacity to return to unrestricted full duty in the military after anterior cervical discectomy and fusion (ACDF) is worthy of analysis.

Objective: To identify the rate of return to full, unrestricted active duty after single and 2-level anterior cervical discectomy, and fusion surgery in military personnel.

Methods: A retrospective chart review was performed at a tertiary care military treatment facility for all active duty personnel who underwent a single or 2-level ACDF over a 4-yr period. Patient and procedural data were collected to include single or 2-level fusion, indication for surgery, fusion level, tobacco use, age, and military rank. Fischer's Exact and Wilcoxon Rank Sum tests were used to identify statistically significant differences in the rate of return to active duty.

Results: A total of 132 anterior cervical discectomy and fusions were analyzed. One hundred sixteen patients (88%) were able to return to unrestricted full active duty, while the remaining 16 required separation from the military for continued pain or disability. The return to active duty rate was significantly higher in service members with a rank of E7 or above (99%) than those E6 and below (73%). There was a strong association between the presence of a pseudoarthrosis and the capacity to return to full duty (P = .013).

Conclusion: Both single and 2-level ACDFs have high overall success with an 88% rate of return to full duty.
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http://dx.doi.org/10.1093/neuros/nyy230DOI Listing
July 2019

Commentary: Trends in the National Resident Matching Program (NRMP) Data for Graduating US Medical Students Matching in Neurosurgery.

Neurosurgery 2018 08;83(2):E65-E70

Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona.

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http://dx.doi.org/10.1093/neuros/nyy181DOI Listing
August 2018

Is Access to Outpatient Neurosurgery Affected by Narrow Insurance Networks? Results From Statewide Analysis of Marketplace Plans in Louisiana.

Neurosurgery 2019 01;84(1):50-59

Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona.

Background: The main objective of the Affordable Care Act (ACA) was to make health insurance affordable to all Americans while addressing the lack of coverage for 48 million people. In the face of rapidly increasing enrollment and rising demand for inexpensive plans, insurance providers are limiting in-network physicians. Provider networks offering plans with limited in-network physicians have become known as "narrow networks."

Objective: To assesses the adequacy of ACA marketplace plans for outpatient neurosurgery in Louisiana.

Methods: The Marketplace Public Use Files were searched for all "silver" plans. A total of 7 silver plans were identified in Louisiana. Using the plans' online directories, a search of in-network neurosurgeons in Louisiana parishes with >100 000 population was performed. The primary outcome was lack of in-network neurosurgeon(s) in silver plans within 50 miles of selected zip code for each parish with >100 000 population. Plans without in-network neurosurgeon(s) are labeled as neurosurgeon-deficient plans.

Results: Several plans in Louisiana are neurosurgeon deficient, ie no in-network neurosurgeon within 50 miles of the designated parish zip code. Company A's plan 3 is deficient in all 5 parishes, while company C and company D silver plans are deficient in 4 out of 14 (29%). Combined results from all counties and plans demonstrate that 43% (3 out of 7) of all silver plans in Louisiana are neurosurgeon deficient in at least 4 parishes with population >100 000.

Conclusion: In Louisiana, narrow networks have limited access to neurosurgical care for those patients with ACA silver plans.
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http://dx.doi.org/10.1093/neuros/nyx632DOI Listing
January 2019

Anatomic Basis for Minimally Invasive Resection of Intradural Extramedullary Lesions in Thoracic Spine.

World Neurosurg 2018 Jan 21;109:e770-e777. Epub 2017 Nov 21.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

Objective: Since the first resections of intradural extramedullary neoplasms, neurosurgeons have tended to preserve as much of the integrity of the spine as possible while ensuring a safe corridor to resect these lesions. A dimensional analysis of intradural lesions superimposed on a dimensional analysis of the thoracic canal would provide the anatomic basis for a minimal access approach. The authors report the results of such an analysis on a series of patients with intradural extramedullary lesions.

Methods: A retrospective analysis was undertaken of 26 thoracic intradural extramedullary lesions managed with open or minimally invasive resection. The size of each lesion was measured in the rostrocaudal, lateral, and anteroposterior dimensions and then averaged and compared with reported dimensions of the thoracic spinal canal.

Results: The mean (range) dimensions of the surgically resected thoracic lesions were 18.6 mm (10-25 mm) for rostrocaudal, 13.0 mm (7-18 mm) for lateral, and 13.6 mm (9-17 mm) for anteroposterior. No patient had any evidence of thoracic canal remodeling.

Conclusions: Thoracic intradural extramedullary lesions become symptomatic as they approach the limits of the thoracic canal, resulting in an inherent dimensional limitation in the rostrocaudal, lateral, and anteroposterior dimensions. Displacement of the spinal cord by the lesion to one side further favors a minimally invasive unilateral approach. A paraspinal unilateral hemilaminectomy approach with a 35 × 20 mm exposure centered over the lesion offers a safe surgical corridor for resection while preserving the posterior tension band, facet complexes, and paraspinal musculature.
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http://dx.doi.org/10.1016/j.wneu.2017.10.078DOI Listing
January 2018

A History of the Council of State Neurosurgical Societies.

Neurosurgery 2017 Jan;80(1):146-157

Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida.

As neurological surgery evolved into its own subspecialty early in the 20th century, a need arose to create an environment for communication and education among those surgeons working in this burgeoning surgical discipline. As the socioeconomic climate in health care began to change in the United States, an unforeseen need arose that was outside the scope of the American Association of Neurological Surgeons, Congress of Neurological Surgeons, and Society of Neurological Surgeons. The capacity to understand and address the evolving socioeconomic landscape and to offer a platform for advocacy required a new entity. Grassroots efforts of neurosurgeons at the state level ultimately yielded a formal organization of state neurosurgical societies to fill this void by recognizing, understanding, and addressing socioeconomic factors affecting the practice of neurological surgery. This formal organization became the Council of State Neurosurgical Societies (CSNS). The CSNS provides a forum in which state societies can meet to identify, understand, and advocate for policies on behalf of organized neurosurgery. The purpose of this paper is to detail the history of the formation of the CSNS. By understanding this history and the need for the development of the CSNS, it is hoped that its evolving role as a voice for neurological surgeons in the modern era of health care will be made clear.
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January 2017

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Posttreatment Follow-up Evaluation of Patients With Nonfunctioning Pituitary Adenomas.

Neurosurgery 2016 Oct;79(4):E541-3

‡Department of Neurosurgery, Seton Brain and Spine Institute, Austin, Texas; §Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts; ¶Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California; ‖Departments of Medicine and Neurological Surgery, Oregon Health Science University, Portland, Oregon; #Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; **Barrow Neurological Institute, Phoenix, Arizona; ‡‡Department of Neurosurgery, Emory University, Atlanta, Georgia; §§Center for Theoretical and Applied Neuro-Oncology, Department of Neuro-Oncology, University of California, San Diego, San Diego, California; ¶¶Department of Neurosurgery, Peking Union Medical College Hospital, Beijing, China; ‖‖Department of Radiology, UC San Diego Health System, University of California, San Diego, San Diego, California; ##Department of Radiology, San Diego Veterans Administration Health System, San Diego, California; ***Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; ‡‡‡Department of Neurosurgery, George Washington University, Washington, DC; §§§Department of Neurological Surgery, University of Southern California, Los Angeles, California; ‖‖‖Department of Neurosurgery, University of California, San Francisco, California.

Background: Nonfunctioning pituitary adenomas (NFPAs) are the most frequent pituitary tumors. Due to the lack of hormonal hypersecretion, posttreatment follow-up evaluation of NFPAs is challenging.

Objective: To create evidence-based guidelines in an attempt to formulate guidance for posttreatment follow-up in a consistent, rigorous, and cost-effective way.

Methods: An extensive literature search was performed. Only clinical articles describing postoperative follow-up of adult patients with NFPAs were included. To ascertain the class of evidence for the posttreatment follow-ups, the authors used the Clinical Assessment evidence-based classification.

Results: Twenty-three studies met the inclusion criteria with respect to answering the questions on the posttreatment radiologic, endocrinologic, and ophthalmologic follow-up. Through this search, the authors formulated evidence-based guidelines for radiologic, endocrinologic, and ophthalmologic follow-up after surgical and/or radiation treatment.

Conclusion: Long-term radiologic, endocrinologic, and ophthalmologic surveillance monitoring after surgical and/or radiation therapy treatment of NFPAs to evaluate for tumor recurrence or regrowth, as well as pituitary and visual status, is recommended. There is insufficient evidence to make a recommendation on the duration of time of surveillance and its frequency. It is recommended that the first radiologic study to evaluate the extent of resection of the NFPA be performed ≥3 months after surgical intervention. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_8.

Abbreviation: NFPA, nonfunctioning pituitary adenoma.
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October 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Residual or Recurrent Nonfunctioning Pituitary Adenomas.

Neurosurgery 2016 Oct;79(4):E539-40

*Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia; ‡Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; §Barrow Neurological Institute, Phoenix, Arizona; ¶Department of Neurosurgery, Emory University, Atlanta, Georgia; ‖Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; #Department of Neurosurgery, George Washington University, Washington, DC; **Department of Neurological Surgery, University of Southern California, Los Angeles, Los Angeles, California; ‡‡Department of Neurosurgery, University of California, San Francisco, San Francisco, California.

Background: Despite the advancement of microsurgical and endoscopic techniques, some nonfunctioning pituitary adenomas (NFPAs) can be difficult to cure. Tumor recurrence or incomplete resection may occur in some patients with NFPAs, and management strategies for these NFPAs remain unclear.

Objective: To review the existing literature as it pertains to the management of postsurgical residual or recurrent NFPAs.

Methods: A systematic review of the treatment options for residual or recurrent NFPAs was performed. In this review, the authors critically evaluated the evidence to support the options of repeat microsurgical resection, stereotactic radiosurgery (SRS), stereotactic radiotherapy (SRT), and fractionated radiation therapy (XRT).

Results: Forty-nine studies met the inclusion criteria for analysis: outcome of repeat surgical resection (n = 4), radiosurgery (ie, single-session or hypofractionated SRS; n = 24), or fractionated radiotherapy (ie, conventional XRT, proton beam radiotherapy, intensity-modulated radiotherapy, SRT; n = 21). No class I evidence was available; 6 studies met criteria for class II evidence; and other studies provided class III evidence. A meta-analysis of 5 class II studies with recurrence rates for both adjuvant radiation therapy and observation demonstrated that XRT for residual/recurrent NFPAs offered a lower rate of recurrence (odds ratio = 0.04; 95% confidence interval, 0.01-0.20; P < .001). The analysis also demonstrated significant heterogeneity between the included studies (χ = 20.70; P = .003; I = 81%).

Conclusion: Repeat resection, SRS, SRT, and XRT play a role in the management of patients with recurrent or residual NFPAs. SRS or some type of radiation therapy is typically performed for patients with residual tumor or tumor recurrence after resection. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_7.

Abbreviations: NFPA, nonfunctioning pituitary adenomaSRS, stereotactic radiosurgerySRT, stereotactic radiotherapyXRT, fractionated radiation therapy.
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October 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Surgical Techniques and Technologies for the Management of Patients With Nonfunctioning Pituitary Adenomas.

Neurosurgery 2016 Oct;79(4):E536-8

‡Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin; §Brain Tumor Center and Pituitary Disorders Program, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California; ¶Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania; ‖Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; #Barrow Neurological Institute, Phoenix, Arizona; **Department of Neurosurgery, Emory University, Atlanta, Georgia; ‡‡Department of Neurosurgery, George Washington University, Washington, DC; §§Department of Neurological Surgery, University of Southern California, Los Angeles, California; ¶¶Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; ‖‖Department of Neurosurgery, University of California, San Francisco, San Francisco, California.

Background: Numerous technological adjuncts are used during transsphenoidal surgery for nonfunctioning pituitary adenomas (NFPAs), including endoscopy, neuronavigation, intraoperative magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) diversion, and dural closure techniques.

Objective: To generate evidence-based guidelines for the use of NFPA surgical techniques and technologies.

Methods: An extensive literature search spanning January 1, 1966, to October 1, 2014, was performed, and only articles pertaining to technological adjuncts for NFPA resection were included. The clinical assessment evidence-based classification was used to ascertain the class of evidence.

Results: Fifty-six studies met the inclusion criteria, and evidence-based guidelines were formulated on the use of endoscopy, neuronavigation, intraoperative MRI, CSF diversion, and dural closure techniques.

Conclusion: Both endoscopic and microscopic transsphenoidal approaches are recommended for symptom relief in patients with NFPAs, with the extent of tumor resection improved by adequate bony exposure and endoscopic visualization. In select cases, combined transcranial and transsphenoidal approaches are recommended. Although intraoperative MRI can improve gross total resection, its use is associated with an increased false-positive rate and is thus not recommended. There is insufficient evidence to recommend the use of neuronavigation, CSF diversion, intrathecal injection, or specific dural closure techniques. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_6.

Abbreviations: CSF, cerebrospinal fluidNFPA, nonfunctioning pituitary adenoma.
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October 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Primary Management of Patients With Nonfunctioning Pituitary Adenomas.

Neurosurgery 2016 Oct;79(4):E533-5

‡Department of Neurological Surgery, University of Southern California, Los Angeles, California; §Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶Barrow Neurological Institute, Phoenix, Arizona; ∥Department of Neurosurgery, Emory University, Atlanta, Georgia; #Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California; **Department of Neurosurgery, George Washington University, Washington, DC; ‡‡Department of Neurosurgery, University of California, San Francisco, California.

Background: Nonfunctioning pituitary adenomas (NFPAs) are among the most common pituitary lesions and may present clinically with vision loss and hypopituitarism.

Objective: To characterize the existing literature as it pertains to the initial management of NFPAs.

Methods: A systematic literature review was conducted to identify and screen articles assessing primary treatment options (surgical, medical, radiation based, or observation) for NFPAs. Outcomes assessed included vision-, endocrine-, and headache-related symptoms, as well as tumor response to therapy. Twenty-five studies met inclusion criteria for analysis.

Results: A considerable amount of class II evidence (14 studies) was identified supporting primary surgical intervention in patients with symptomatic NFPA macroadenomas, resulting in immediate tumor volume reduction in nearly all patients and a residual tumor rate of 10% to 36%. One prospective, observational cohort study and multiple retrospective studies showed improved visual function in 75% to 91% of surgically treated patients and improved hypopituitarism in 35% to 50% of patients. Limited class II evidence showed inconsistent benefits for observation alone (1 study), primary radiation-based treatment (3 studies), or primary medical treatment (8 studies) for improving vision, headaches, hypopituitarism, or tumor volume. One retrospective study implementing observation alone showed tumor progression in 50% of patients and a requirement for surgery in 21% of patients. Eight studies assessing primary medical therapy for NFPAs showed inconsistent tumor response rates using somatostatin analogs (12%-40% response rate), dopamine agonist therapy (0%-61% response rate), or combination therapy (60% response rate). Three studies reporting primary radiosurgery for NFPAs showed decreased tumor size in 38% to 60% of patients.

Conclusion: Multiple retrospective and some prospective studies have demonstrated consistent effectiveness of primary surgical resection of symptomatic NFPAs with acceptable morbidity rates. Limited and inconsistent reports are available for alternative treatment strategies, including radiation, medical treatment, and observation alone; these modalities may, however, play a valid role in patients who are not surgical candidates. Based on the available evidence, the authors recommend surgical resection as the preferred primary intervention for symptomatic NFPAs. The full guidelines document for this chapter can be located at https://www.cns.org/guidelines/guidelines-management-patients-non-functioning-pituitary-adenomas/Chapter_5.

Abbreviation: NFPA, nonfunctioning pituitary adenoma.
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October 2016