Publications by authors named "Nikita Lakomkin"

73 Publications

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

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

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

Study Design: Prospective single-cohort analysis.

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

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

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

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

Lower Hounsfield Units at the Upper Instrumented Vertebrae are Significantly Associated With Proximal Junctional Kyphosis and Failure Near the Thoracolumbar Junction.

Oper Neurosurg (Hagerstown) 2021 Jun 25. Epub 2021 Jun 25.

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: Low bone mineral density (BMD) on dual energy x-ray absorptiometry (DXA) is likely a risk factor for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). However, prior instrumentation and degenerative changes can preclude a lumbar BMD measurement. Hounsfield units (HU) represent an alternative method to estimate BMD via targeted measurements at the intended operative levels.

Objective: To determine if patients with lower HU at the upper instrumented vertebrae (UIV) and vertebral body superior to the UIV (UIV + 1) are at greater risk for PJK and PJF.

Methods: A retrospective chart review identified patients at least 50 yr of age who underwent instrumented lumbar fusion with pelvic fixation, a UIV from T10 to L2, and a preoperative computed tomography (CT) encompassing the UIV. HU were measured at the UIV, UIV + 1, and the L3-L4 vertebral bodies.

Results: A total of 150 patients (80 women and 70 men) were included with an average age of 66 yr and average follow-up of 32 mo. Multivariable logistic regression analysis with an area under the curve (AUC) of 0.89 demonstrated HU at the UIV/UIV + 1 as the only independent predictor of PJK/PJF with an odds ratio of 0.94 (P-value = .031) for a change in a single HU. Patients with HU at UIV/UIV + 1 of <110 (n = 35), 110 to 160 (n = 73), and >160 (n = 42) had a rate of PJK/PJF of 63%, 27%, and 12%, respectively (P-value < .001).

Conclusion: Patients with lower HU at the UIV and UIV + 1 were significantly associated with PJK and PJF, with an optimal cutoff of 122 HU that maximizes sensitivity and specificity.
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http://dx.doi.org/10.1093/ons/opab236DOI Listing
June 2021

Fenestrated pedicle screws for thoracolumbar instrumentation in patients with poor bone quality: Case series and systematic review of the literature.

Clin Neurol Neurosurg 2021 Jul 11;206:106675. Epub 2021 May 11.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY 11030, USA. Electronic address:

Objective: To describe the results of a single-surgeon series and systematically review the literature on cement-augmented instrumented fusion with fenestrated pedicle screws.

Methods: All patients treated by the senior surgeon using fenestrated screws between 2017 and 2019 with a minimum of 6-months of clinical and radiographic follow-up were included. For the systematic review, we used PRISMA guidelines to identify all prior descriptions of cement-augmented instrumented fusion with fenestrated pedicle screws in the English literature. Endpoints of interest included hardware loosening, cement leakage, and pulmonary cement embolism (PCE).

Results: Our series included 38 patients (mean follow-up 14.8 months) who underwent cement-augmented instrumentation for tumor (47.3%), deformity/degenerative disease (39.5%), or osteoporotic fracture (13.2%). Asymptomatic screw lucency was seen in 2.6%, cement leakage in 445, and pulmonary cement embolism (PCE) in 5.2%. Our literature review identified 23 studies (n = 1526 patients), with low reported rates of hardware loosening (0.2%) and symptomatic PCE (1.0%). Cement leakage, while common (55.6%), produced symptoms in fewer than 1% of patients. Indications for cement-augmentation in this cohort included: spine metastasis with or without pathologic fracture (n = 18; 47.3%), degenerative spine disease or fixed deformity with poor underlying bone quality (n = 15; 39.5%), and osteoporotic fracture (n = 5; 13.2%).

Conclusion: Cement-augmented fusion with fenestrated screws appears to be a safe, effective means of treating patients with poor underlying bone quality secondary to tumor or osteoporosis. High-quality evidence with direct comparisons to non-augmented patients is needed.
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http://dx.doi.org/10.1016/j.clineuro.2021.106675DOI Listing
July 2021

In Reply: The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement.

Neurosurgery 2021 Jun;89(1):E104

Department of Neurosurgery Icahn School of Medicine at Mount Sinai Mount Sinai Health System New York, New York, USA.

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http://dx.doi.org/10.1093/neuros/nyab145DOI Listing
June 2021

Fluorescence-Guided High-Grade Glioma Surgery More Than Four Hours After 5-Aminolevulinic Acid Administration.

Front Neurol 2021 9;12:644804. Epub 2021 Mar 9.

Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States.

Fluorescence-guided surgery (FGS) using 5-aminolevulic acid (5-ALA) is a widely used strategy for delineating tumor tissue from surrounding brain intraoperatively during high-grade glioma (HGG) resection. 5-ALA reaches peak plasma levels ~4 h after oral administration and is currently approved by the FDA for use 2-4 h prior to induction to anesthesia. To demonstrate that there is adequate intraoperative fluorescence in cases undergoing surgery more than 4 h after 5-ALA administration and compare survival and radiological recurrence to previous data. Retrospective analysis of HGG patients undergoing FGS more than 4 h after 5-ALA administration was performed at two institutions. Clinical, operative, and radiographic pre- and post-operative characteristics are presented. Sixteen patients were identified, 6 of them female (37.5%), with mean (SD) age of 59.3 ± 11.5 years. Preoperative mean modified Rankin score (mRS) was 2 ± 1. All patients were dosed with 20 mg/kg 5-ALA the morning of surgery. Mean time to anesthesia induction was 425 ± 334 min. All cases had adequate intraoperative fluorescence. Eloquent cortex was involved in 12 cases (75%), and 13 cases (81.3%) had residual contrast enhancement on postoperative MRI. Mean progression-free survival was 5 ± 3 months. In the study period, 6 patients died (37.5%), mean mRS was 2.3 ± 1.3, Karnofsky score 71.9 ± 22.1, and NIHSS 3.9 ± 2.4. Here we demonstrate that 5-ALA-guided HGG resection can be performed safely more than 4 h after administration, with clinical results largely similar to previous reports. Relaxation of timing restrictions could improve procedure workflow in busy neurosurgical centers, without additional risk to patients.
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http://dx.doi.org/10.3389/fneur.2021.644804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985355PMC
March 2021

Collision of Craniopharyngioma and Pituitary Adenoma: Comprehensive Review of an Extremely Rare Sellar Condition.

World Neurosurg 2021 May 26;149:e51-e62. Epub 2021 Feb 26.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Objective: The collision of pituitary adenoma and craniopharyngioma is extremely rare and thus there remains a paucity of data.

Methods: We described a patient from our institution. We also performed a systematic review and subsequent quantitative synthesis of the literature (n = 21) and our institutional case to yield an integrated cohort, and a descriptive analysis was carried out.

Results: Twenty-two patients (15 males and 7 females) were included in the integrated cohort. The median age was 47.0 years (range, 8-75 years). The tumor subtypes were 5 somatotropic, 5 lactotropic, 4 nonfunctioning, 3 gonadotropic, 2 corticotropic, 1 plurihormonal, and 1 silent subtype 3 for pituitary adenomas, and 19 adamantinomatous, 2 papillary, and 1 unknown subtype for craniopharyngiomas. Three different radiographic patterns were observed: solid mass with cystic component (n = 5), coexistence of two distinct solid components (n = 3), and a mixed-intensity solid mass (n = 5). The first 2 were consistent with histologically separate collision, whereas the third was consistent with histologically admixed collision. Among 19 patients in whom the postoperative course was recorded, a secondary intervention was required in 14 (73.7%) because of tumor progression or residual. The recurrence rate after gross total resection was 33.3%. Postoperative hormone replacement was required in 33.3%. The 10-year cumulative overall survival was 73.1%.

Conclusions: Most craniopharyngiomas were adamantinomatous. There are 2 types of collisions: separated and admixed. Tumor control, overall survival, and endocrinologic remission are more challenging to achieve than for solitary tumors, but gross total resection of both tumors is important for satisfactory tumor control.
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http://dx.doi.org/10.1016/j.wneu.2021.02.091DOI Listing
May 2021

Fluorescence guided surgery for pituitary adenomas.

J Neurooncol 2021 Feb 21;151(3):403-413. Epub 2021 Feb 21.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai Downtown Union Square, 10 Union Square East, Suite 5E, New York, NY, 10003, USA.

Purpose: Resection of pituitary adenomas presents a number of unique challenges in neuro-oncology. The proximity of these lesions to key vascular and endocrine structures as well as the need to interpret neuronavigation in the context of shifting tumor position increases the complexity of the operation. More recently, substantial advances in fluorescence-guided surgery have been demonstrated to facilitate the identification of numerous tumor types and result in increased rates of complete resection and overall survival.

Methods: A review of the literature was performed, and data regarding the mechanism of the fluorescence agents, their administration, and intraoperative tumor visualization were extracted. Both in vitro and in vivo studies were assessed. The application of these agents to pituitary tumors, their advantages and limitations, as well as future directions are presented here.

Results: Numerous laboratory and clinical studies have described the use of 5-ALA, fluorescein, indocyanine green, and OTL38 in pituitary lesions. All of these drugs have been demonstrated to accumulate in tumor cells. Several studies have reported the successful use of the majority of the agents in inducing intraoperative tumor fluorescence. However, their sensitivity and specificity varies across the literature and between functioning and non-functioning adenomas.

Conclusions: At present, numerous studies have shown the feasibility and safety of these agents for pituitary adenomas. However, further research is needed to assess the applicability of fluorescence-guided surgery across different tumor subtypes as well as explore the relationship between their use and postoperative clinical outcomes.
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http://dx.doi.org/10.1007/s11060-020-03420-zDOI Listing
February 2021

Medical Student Publications in Neurosurgery: At Which U.S. Academic Institutions Do Medical Students Publish Most?

World Neurosurg 2021 03 16;147:181-189.e1. Epub 2020 Dec 16.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Neurosurgery, Mount Sinai Beth Israel, New York, New York, USA. Electronic address:

Background: The neurosurgery residency match is a competitive process. While medical research offers esteemed learning opportunities, productivity is closely evaluated by residency programs. Accordingly, students work diligently to make contributions on projects within their neurosurgery departments. The present study evaluated medical student research productivity for each of the 118 U.S. neurosurgery residency programs.

Methods: A retrospective review of publications for 118 neurosurgery programs from January 1, 2015, to April 1, 2020, was performed. The primary outcome was any publication with a medical student as the first author. Secondary outcomes included number of faculty in each department, department region, and medical school ranking. The number of student first author publications was compared among programs, regions, and medical schools.

Results: Mean numbers of medical student first author publications and faculty members per institution were 16.27 and 14.46, respectively. The top 3 neurosurgery departments with the greatest number of student first author publications were Johns Hopkins University, Brigham and Women's Hospital, and University of California, San Francisco. Salient findings included a positive correlation between the number of medical student first author publications from a neurosurgery department and the number of departmental faculty (P < 0.001, R = 0.69). Additionally, the mean number of first author medical student publications at the top 30 programs was higher than the mean for the remaining programs (P < 0.0001).

Conclusions: This study is the first to evaluate neurosurgery medical student productivity in North America. By systematizing first authorships, incoming students who desire to pursue neurosurgery can be informed of institutions with student involvement, and departments that use medical student expertise can be recognized.
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http://dx.doi.org/10.1016/j.wneu.2020.12.045DOI Listing
March 2021

Predictors of Readmission and Prolonged Length of Stay After Cervical Disc Arthroplasty.

Spine (Phila Pa 1976) 2021 Apr;46(8):487-491

Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT.

Study Design: Retrospective cohort study.

Objective: The aim of the study was to assess which factors increase risk of readmission within 30 days of surgery or prolonged length of stay (LOS) (≥2 days) after cervical disc arthroplasty (CDA).

Summary Of Background Data: Several studies have shown noninferiority at mid- and long-term outcomes after cervical disc arthroplasty (CDA) compared to anterior cervical discectomy and fusion ACDF, but few have evaluated short-term outcomes regarding risk of readmission or prolonged LOS after surgery.

Methods: Demographics, comorbidities, operative details, postoperative complications, and perioperative outcomes were collected for patients undergoing single level CDA in the National Surgical Quality Improvement Program (NSQIP) database. Patients with prolonged LOS, defined as >2 days, and readmission within 30 days following CDA were identified. Univariable and multivariable logistic regression models were used to identify risk factors for prolonged LOS and readmission.

Results: A total of 3221 patients underwent single level CDA. Average age was 45.6 years (range 19-82) and 53% of patients were male. A total of 472 (14.7%) experienced a prolonged LOS and 36 (1.1%) patients were readmitted within 30 days following surgery. Predictors of readmission were postoperative superficial wound infection (odds ratio [OR] = 73.83, P < 0.001), American Society of Anesthesiologists (ASA) classification (OR = 1.98, P = 0.048), and body mass index (BMI) (OR = 1.06, P = 0.02). Female sex (OR = 1.76, P < 0.001), diabetes (OR = 1.50, P = 0.024), postoperative wound dehiscence (OR = 13.11, P = 0.042), ASA class (OR = 1.43, P < 0.01), and operative time (OR = 1.01, P < 0.001) were significantly associated with prolonged LOS.

Conclusion: From a nationwide database analysis of 3221 patients, wound complications are predictors of both prolonged LOS and readmission. Patient comorbidities, including diabetes, higher ASA classification, female sex, and higher BMI also increased risk of prolonged LOS or readmission.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003839DOI Listing
April 2021

The Utility of Preoperative Labs in Predicting Postoperative Complications Following Primary Total Hip and Knee Arthroplasty.

Bull Hosp Jt Dis (2013) 2020 12;78(4):266-274

Background: Preoperative testing costs billions of dollars despite little evidence supporting its utility. The purpose of this study was to determine the relationship between abnormal preoperative laboratory tests and postoperative complications following total joint arthroplasty.

Methods: The NSQIP database was used to identify 45,936 primary total hip arthroplasty (THA) and 76,041 pri-mary total knee arthroplasty (TKA) cases performed between 2006 and 2013. Complications within 30 days of surgery were collected and multivariable regression modeling was performed incorporating all significant laboratory values as well as demographics and preoperative comorbidities.

Results: For THA patients, abnormal sodium (p = 0.016, OR = 1.89), white count (p = 0.043, OR = 1.73), and partial thromboplastin time (p = 0.028, OR = 1.43) were significantly associated with complications. For TKA patients, abnormal alkaline phosphatase (p = 0.04, OR = 2.12), creatinine (p = 0.003, OR = 1.56), and INR (p = 0.008, OR = 1.99) were significantly predictive of complications.

Conclusion: Of the 13 laboratory values, only six were significantly associated with complications. These findings may have implications for risk stratification in the inpatient setting.
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December 2020

The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement.

Neurosurgery 2021 01;88(2):301-305

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York.

Background: Ventriculoperitoneal shunt placement remains the primary treatment modality for children with hydrocephalus. However, morbidity and revision surgery secondary to infection remains high, even while using antibiotic-impregnated shunts.

Objective: To determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement.

Methods: This is an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephalus were included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection.

Results: A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio = 0.29, 95% CI: 0.04-0.89, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.38%) went on to undergo re-intervention due to infection.

Conclusion: These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection.
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http://dx.doi.org/10.1093/neuros/nyaa413DOI Listing
January 2021

Spinal cord injury in the United States Army Special Forces.

J Neurosurg Spine 2020 Sep 25:1-7. Epub 2020 Sep 25.

3Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio.

Objective: Spinal cord injury (SCI) is an area of key interest in military medicine but has not been studied among the US Army Special Forces (SF), the most elite group of US soldiers. SF soldiers make up a disproportionate 60% of all Special Operations casualties. The objective of this study was to better understand SCI incidence in the SF, its mechanisms of acquisition, and potential areas for intervention by addressing key issues pertaining to protective equipment and body armor use.

Methods: An electronic survey questionnaire was formulated with the close collaboration of US board-certified neurosurgeons from the Mount Sinai Hospital and Cleveland Clinic Departments of Neurosurgery, retired military personnel of the SF, and operational staff of the Green Beret Foundation. The survey was sent to approximately 6000 SF soldiers to understand SCI diagnosis and its associations with various health and military variables.

Results: The response rate was 8.2%. Among the 492 respondents, 94 (19.1%) self-reported an SCI diagnosis. An airborne operation was the most commonly attributed cause (54.8%). Moreover, 87.1% of SF soldiers reported wearing headgear at the time of injury, but only 36.6% reported wearing body armor, even though body armor use has significantly increased in post-9/11 SF soldiers compared with that in their pre-9/11 counterparts. SCI was significantly associated with traumatic brain injury, arthritis, low sperm count, low testosterone, erectile dysfunction, tinnitus, hyperacusis, sleep apnea, posttraumatic stress disorder, major depressive disorder, and generalized anxiety disorder. Only 16.5% of SF soldiers diagnosed with SCI had been rescued via medical evacuation (medevac) for treatment.

Conclusions: A high number of SF soldiers self-reported an SCI diagnosis. Airborne operations landings were the leading cause of SCI, which coincided with warfare tactics employed during the Persian Gulf War, Operation Iraqi Freedom, and other conflicts. A majority of SCIs occurred while wearing headgear and no body armor, suggesting the need for improvements in protective equipment use and design. The low rate of medevac rescue for these injuries may suggest that medical rescue was not attainable at the time or that certain SCIs were deemed minor at the time of injury.
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http://dx.doi.org/10.3171/2020.7.SPINE20804DOI Listing
September 2020

Postoperative outcomes following glioblastoma resection using a robot-assisted digital surgical exoscope: a case series.

J Neurooncol 2020 Jul 9;148(3):519-527. Epub 2020 Jun 9.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY, USA.

Introduction: Maximal extent of resection (EOR) of glioblastoma (GBM) is associated with greater progression free survival (PFS) and improved patient outcomes. Recently, a novel surgical system has been developed that includes a 2D, robotically-controlled exoscope and brain tractography display. The purpose of this study was to assess outcomes in a series of patients with GBM undergoing resections using this surgical exoscope.

Methods: A retrospective review was conducted for robotic exoscope assisted GBM resections between 2017 and 2019. EOR was computed from volumetric analyses of pre- and post-operative MRIs. Demographics, pathology/MGMT status, imaging, treatment, and outcomes data were collected. The relationship between these perioperative variables and discharge disposition as well as progression-free survival (PFS) was explored.

Results: A total of 26 patients with GBM (median age = 57 years) met inclusion criteria, comprising a total of 28 cases. Of these, 22 (79%) tumors were in eloquent regions, most commonly in the frontal lobe (14 cases, 50%). The median pre- and post-operative volumes were 24.0 cc and 1.3 cc, respectively. The median extent of resection for the cohort was 94.8%, with 86% achieving 6-month PFS. The most common neurological complication was a motor deficit followed by sensory loss, while 8 patients (29%) were symptom-free.

Conclusions: The robotic exoscope is safe and effective for patients undergoing GBM surgery, with a majority achieving large-volume resections. These patients experienced complication profiles similar to those undergoing treatment with the traditional microscope. Further studies are needed to assess direct comparisons between exoscope and microscope-assisted GBM resection.
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http://dx.doi.org/10.1007/s11060-020-03543-3DOI Listing
July 2020

Shaping Our Understanding of Medulloblastoma: A Bibliometric Analysis of the 100 Most Cited Articles.

Clin Neurol Neurosurg 2020 07 23;194:105895. Epub 2020 May 23.

Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, United States. Electronic address:

The clinical management of medulloblastoma has undergone significant transformation since the recent dawn of the molecular era. The aim of this analysis was to evaluate citation and other bibliometric characteristics of the 100 most cited medulloblastoma articles in the literature to better understand the current state of our research efforts into this diagnosis. Elsevier's Scopus database was searched for the 100 most cited articles that focused on medulloblastoma. Articles were dichotomized as either primarily basic science (BSc) or clinical (CL) articles. Various bibliometric parameters were summarized and compared between BSc and CL articles using Pearson's Chi-square and Mann Whitney U tests. Of the 100 most cited articles, 52 were characterized as BSc articles and 48 as CL articles. Overall median (range) values were as follows: citation count 252 (164-1,270); citation rate per year 17.5 (2.5-110); number of authors 11 (1-135); and publication year 2005 (1925-2014). Articles were published in a total of 40 different journals, and the majority originated in the US (n = 60). When compared to CL articles, BSc articles reported significantly greater citation rates per year (P < 0.01), and more recent years of publication (P < 0.01). In summary, although similar in overall proportion, BSc articles demonstrated significantly increased bibliometric parameters of impact in this field by the successful clustering molecular subtypes. Moving forward, it will be of great interest to see how the findings from these impactful BSc articles will translate into future clinical initiatives and subsequently high-impact CL articles.
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http://dx.doi.org/10.1016/j.clineuro.2020.105895DOI Listing
July 2020

Diffusion MRI Reversibility in Ischemic Stroke Following Thrombolysis: A Meta-Analysis.

J Neuroimaging 2020 07 20;30(4):471-476. Epub 2020 May 20.

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

Background And Purpose: Diffusion-weighted magnetic resonance imaging (DWI) detects early infarction in acute stroke. With the substantial progress in stroke therapies, the frequency of posttreatment DWI reversibility in modern stroke cohorts is currently unknown. The purpose of this study was to perform a systematic literature review examining the relationship between characteristics of patients with ischemic stroke and DWI reversibility following treatment with lytic therapy.

Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, yielding a total of 422 unique articles. Studies that were nonclinical or did not report data pertaining to DWI reversibility in the context of an acute stroke series were excluded. Characteristics regarding presentation, diagnosis, intervention, and the timing of DWI reversibility were collected for each study.

Results: After full-text review, 10 studies were identified as meeting inclusion criteria. The number of patients with DWI reversal ranged from .9% to 50%, whereas the extent of reversal ranged from 1.8% to 72.7%. Studies reporting on younger patients describe greater rates of reversibility following stroke treatment.

Conclusions: These data suggest that early DWI signal may not represent the definitive DWI burden in recanalized populations. However, substantial heterogeneity exists regarding the rate of DWI reversal following recanalization. Additional studies are needed to elucidate the relationship among time to treatment, early reversal rates, and clinical outcomes. Physicians should use caution when basing clinical decisions on DWI lesion volumes, as these likely change to some degree with recanalization.
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http://dx.doi.org/10.1111/jon.12703DOI Listing
July 2020

The Role of Imaging in Health Screening: Overview, Rationale of Screening, and Screening Economics.

Acad Radiol 2021 04 12;28(4):540-547. Epub 2020 May 12.

Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas.

Imaging screening examinations are growing in their indications and volume to identify conditions at an early, treatable stage. The Radiology Research Alliance's 'Role of Imaging in Health Screening' Task Force provides a review of imaging-based screening rationale, economics, and describes established guidelines by various organizations. Various imaging modalities can be employed in screening, and are often chosen based on the specific pathology and patient characteristics. Prevalent disease processes with identifiable progression patterns that benefit from early potentially curative interventions are ideal for screening. Two such examples include colonic precancerous polyp progression to adenocarcinoma in colon cancer formation and atypical ductal hyperplasia progression to ductal carcinoma in situ and invasive ductal carcinoma in breast cancer. Economic factors in imaging-based screening are reviewed, including in the context of value-based reimbursements. Global differences in screening are outlined, along with the role of various organizational guidelines, including the American Cancer Society, the US Preventive Services Task Force, and the American College of Radiology.
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http://dx.doi.org/10.1016/j.acra.2020.03.038DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655697PMC
April 2021

The Role of Imaging in Health Screening: Screening for Specific Conditions.

Acad Radiol 2021 04 11;28(4):548-563. Epub 2020 May 11.

Department of Breast Imaging, The University of Texas MD Anderson Cancer Center; Houston, Texas.

There are well-established and emerging screening examinations aimed at identifying malignant and nonmalignant conditions at early, treatable stages. The Radiology Research Alliance's "Role of Imaging in Health Screening" Task Force provides a comprehensive review of specific imaging-based screening examinations. This work reviews and serves as a reference for screening examinations for breast and colon cancer in a healthy population along with screening for lung cancer, hepatocellular carcinoma, and the use of whole body magnetic resonance imaging in at-risk individuals. American College of Radiology scoring systems, along with case-based examples, are included to illustrate the different disease entities. The future of screening is discussed, particularly in the context of artificial intelligence.
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http://dx.doi.org/10.1016/j.acra.2020.03.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655640PMC
April 2021

The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review.

JBJS Rev 2020 04;8(4):e0085

Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY.

Background: Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty.

Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article.

Results: A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates.

Conclusions: Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00085DOI Listing
April 2020

Specific causes and predictors of readmissions following acute and chronic subdural hematoma evacuation.

J Clin Neurosci 2020 May 31;75:35-39. Epub 2020 Mar 31.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, USA; Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, USA. Electronic address:

Patients treated with craniotomy for subdural hematoma (SDH) evacuation have a higher readmission incidence when compared to other neurosurgical patients. Factors predictive of readmission following craniotomy for SDH are incompletely understood. The National Surgical Quality Improvement (NSQIP) database was queried for all patients treated by craniotomy for SDH of any etiology (e.g. acute, chronic, spontaneous, traumatic) during the study period (2012-2014). Patients requiring repeat hospitalization within 30 days of surgery were identified and classified by reason for readmission. Binary logistic regression analysis was used to identify predictors of readmission. 1024 patients met inclusion criteria, among whom 109 (10.6%) were readmitted within 30 days. The most common causes of readmission were recurrent SDH (n = 27; 33.3%), seizure (n = 8; 9.9%), new neurological deficit (n = 6; 7.4%), stroke (n = 6; 7.4%), and altered mental status (AMS) (n = 6; 7.4%). Multivariable modeling identified hypertension requiring medication (OR = 2.78, P = 0.013) and abnormal INR (OR = 2.66, P = 0.035) as significantly associated with readmission following chronic SDH, while postoperative UTI (OR = 3.64, P = 0.01) and stroke (OR = 4.86, P = 0.018) were significant predictors of readmission following acute SDH. Readmission was associated with recurrent hemorrhage after chronic/spontaneous SDH, while seizures, AMS, and neurological deficits drove readmissions after acute/traumatic SDH. Careful management of anticoagulation and antihypertensive medications may be helpful in reducing the risk of readmission following craniotomy for chronic SDH.
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http://dx.doi.org/10.1016/j.jocn.2020.03.042DOI Listing
May 2020

Identifying the Most Appropriate ACDF Patients for an Ambulatory Surgery Center: A Pilot Study Using Inpatient and Outpatient Hospital Data.

Clin Spine Surg 2020 12;33(10):418-423

Orthopaedic of Steamboat Springs, Steamboat Springs, CO.

Study Design: Retrospective cohort analysis of prospectively collected data.

Objectives: Using a national cohort of patients undergoing elective anterior cervical discectomy and fusion (ACDF) in an inpatient/outpatient setting, the current objectives were to: (1) outline preoperative factors that were associated with complications, and (2) describe potentially catastrophic complications so that this data can help stratify the best suited patients for an ambulatory surgery center (ASC) compared with a hospital setting.

Summary Of Background Data: ASCs are increasingly utilized for spinal procedures and represent an enormous opportunity for cost savings. However, ASCs have come under scrutiny for profit-driven motives, lack of adequate safety measures, and inability to handle complications.

Methods: Adults who underwent ACDF between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure ACDF [Current Procedural Terminology (CPT) 22551, 22552], elective, neurological/orthopedic surgeons, length of stayof 0/1 day, and being discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications.

Results: A total of 12,169 patients underwent elective ACDF with a length of stay of 0/1 day and were discharged directly home. A total of 179 (1.47%) patients experienced a complication. Multivariate logistic regression revealed the following factors were significantly associated with a complication: Charlson Comorbidity Index (CCI) >3, history of transient ischemic attack/cerebrovascular accident, abnormal bilirubin, and operative time of >2 hours. Approximate comorbidity score cutoffs associated with <2% risk of complication were: American Society of Anesthesiologists (ASA)≤2, CCI≤2, modified frailty index (mFI) ≤0.182. A total of 51 (0.4%) patients experienced potentially catastrophic complications.

Conclusions: The current results represent a preliminary, pilot analysis using inpatient/outpatient data in selecting appropriate patients for an ASC. The incidence of potentially catastrophic complication was 0.4%. These results should be validated in multi-institution studies to further optimize appropriate patient selection for ASCs.
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http://dx.doi.org/10.1097/BSD.0000000000000967DOI Listing
December 2020

Identifying the most appropriate lumbar decompression patients for ambulatory surgery centers - A pilot study using inpatient and outpatient hospital data.

J Clin Neurosci 2020 Feb 16;72:206-210. Epub 2019 Dec 16.

Orthopaedic of Steamboat Springs, Steamboat Springs, CO, United States.

Introduction: To minimize healthcare related costs, ambulatory surgery centers (ASCs) have become increasingly favored venues for outpatient spine surgery. Using a national cohort of patients undergoing elective lumbar decompression (LD) in an inpatient or outpatient hospital setting, the current objectives were to: 1) outline specific factors that were associated with complications, and 2) describe potentially catastrophic complications.

Methods: Adults who underwent LD between 2008 and 2014 were identified in the National Surgical Quality Improvement Program (NSQIP) database. Inclusion criteria were: principal procedure LD (CPT 63030), elective, neurologic/orthopaedic surgeons, length of stay (LOS) of 0/1 days, and discharged home. The primary outcome was presence of any complication. The secondary outcome was occurrence of potentially catastrophic complications. Univariate/multivariable logistic regression was performed.

Results: A total of 19,908 patients met the inclusion criteria. 564 (2.83%) patients experienced a complication. Cardiac intervention remained the only independent predictor of complications after multivariate testing (OR: 2.02, 95% CI: 1.00, 4.07, p = 0.049). Approximate comorbidity score cut-offs associated with <2% risk of complication were: ASA ≤ 3, CCI ≤ 5, mFI ≤ 0.182. A total of 96 (0.48%) patients experienced potentially catastrophic complications.

Conclusions: We utilized a national cohort of patients undergoing elective inpatient and outpatient LD in a hospital setting to identify preoperative risk factors for postoperative complications. Previous cardiac intervention was the sole independent predictor of complications. Although no patients treated at ASCs were studied, we believe these factors can aid in selecting patients most appropriate for ASCs and begin the process of selecting the best patients for an ambulatory setting.
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http://dx.doi.org/10.1016/j.jocn.2019.12.004DOI Listing
February 2020

Comprehensive Wound Risk Stratification of Rib-Based Distraction Instrumentation Procedures.

Spine Deform 2019 11;7(6):971-978

Division of Orthopaedics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA.

Study Design: Single-center retrospective analysis of a prospectively collected registry.

Objectives: Identify factors predictive of rib-based distraction (RBD) instrumentation wound complication. Create a risk stratification model for RBD instrumentation wound complication.

Summary Of Background Data: RBD instrumentation procedures have a high rate of wound complications, often requiring unplanned operative treatment. Currently, there is a relative lack of understanding of RBD complication risk factors compared with the comprehensive understanding of complication risk factors for other spine surgeries.

Methods: Between January 2011 and September 2015, patients treated with RBD instrumentation at a single institution were analyzed for risk factors associated with surgical wound complications that resulted in unplanned operative treatment. Univariate logistic regression determined predictors of wound complication and multivariate regression determined independent predictive factors; α = 0.10.

Results: A total of 122 patients aged 0-18 years underwent 140 implant surgeries in which 22 resulted in complications: 18 (82%) infectious and 4 (18%) noninfectious. Mean age at surgery was 5.2 years. Univariate analysis showed a correlation between wound complication rates and the following: male gender (p = .097), diapered patient with lower back incision (p = .004), bilateral procedure (p = .008), more than three incisions (p = .011), left iliac incision (p = .097), right iliac incision (p = .009), patient age ≤4 years (p = .10), and operative time >150 minutes (p = .079). Multivariate analysis identified the following independent predictors: age ≤ 4 years (p = .002), male gender (p = .04), number of skin incisions (p = .001), left iliac incision (p = .018), and nutritionally challenged (p = .044). The multivariate model predicted wound complications with an area under the receiver operating characteristic curve of 0.88.

Conclusions: Knowledge of risk factors for RBD instrumentation wound complications can be used to construct patient risk models. This can identify patients at higher risk for complications and influence clinical decision making.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jspd.2019.04.009DOI Listing
November 2019

A predictive model for increased hospital length of stay following geriatric hip fracture.

J Clin Orthop Trauma 2019 Oct 1;10(Suppl 1):S84-S87. Epub 2019 Apr 1.

The Vanderbilt Orthopaedic Institute Center for Health Policy, 1215 21st Avenue South, Suite 4200 Medical Center East, South Tower Nashville, TN, 37232, USA.

Background: The purpose of this study was to identify the risk factors that are significantly associated with hospital length of stay (LOS) following geriatric hip fracture and to use these significant variables to develop a LOS calculator.

Materials And Methods: This was a retrospective study examining 614 patients treated for geriatric hip fracture between January 2000 and December 2009 at an urban, Level 1 trauma center. A negative binomial regression analysis was used to identify perioperative variables associated with hospital LOS.

Results: 614 patients met the inclusion criteria, presenting with a mean age of 78 (±10) years. The most common pre-operative comorbidity was hypertension, followed by diabetes and COPD. After controlling for all collected comorbidities as well as demographics and operative variables, hypertension (IRR: 1.10, p = 0.029) and disseminated cancer (IRR: 1.24, p = 0.007) were found to be significantly associated with LOS. In addition, two demographic/presenting variables, admission to the medicine service (IRR: 1.48, p < 0.001) and male sex (IRR: 1.09, p = 0.034), were shown to be independent risk factors for prolonged LOS. These variables were synthesized into a LOS formula, which estimated LOS to within 3 days of the true length of stay for 0.758 of the series (95% confidence interval: 0.661 to 0.855).

Conclusions: This study identified several comorbidity and perioperative variables that were significantly associated with LOS following geriatric hip fracture surgery. The resulting LOS model may have utility in the risk stratification of orthopaedic trauma patients presenting with hip fracture.
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http://dx.doi.org/10.1016/j.jcot.2019.03.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823779PMC
October 2019

Validating the Transformation of PROMIS-GH to EQ-5D in Adult Spine Patients.

J Clin Med 2019 Sep 20;8(10). Epub 2019 Sep 20.

Department of Neurosurgery, Yale School of Medicine, New Haven, CT 06511, USA.

Spinal disorders and associated interventions are costly in the United States, putting them in the limelight of economic analyses. The Patient-Reported Outcomes Measurement Information System Global Health Survey (PROMIS-GHS) requires mapping to other surveys for economic investigation. Previous studies have proposed transformations of PROMIS-GHS to EuroQol 5-Dimension (EQ-5D) health index scores. These models require validation in adult spine patients. In our study, PROMIS-GHS and EQ-5D were randomly administered to 121 adult spine patients. The actual health index scores were calculated from the EQ-5D instrument and estimated scores were calculated from the PROMIS-GHS responses with six models. Goodness-of-fit for each model was determined using the coefficient of determination (), mean squared error (MSE), and mean absolute error (MAE). Among the models, the model treating the eight PROMIS-GHS items as categorical variables (CAT) was the optimal model with the highest (0.59) and lowest MSE (0.02) and MAE (0.11) in our spine sample population. Subgroup analysis showed good predictions of the mean EQ-5D by gender, age groups, education levels, etc. The transformation from PROMIS-GHS to EQ-5D had a high accuracy of mean estimate on a group level, but not at the individual level.
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http://dx.doi.org/10.3390/jcm8101506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6832387PMC
September 2019

Preoperative Risk Stratification in Spine Tumor Surgery: A Comparison of the Modified Charlson Index, Frailty Index, and ASA Score.

Spine (Phila Pa 1976) 2019 Jul;44(13):E782-E787

Department of Neurosurgery, University of Cincinnati, Cincinnati, OH.

Study Design: A retrospective review of prospectively collected data.

Objective: The purpose of this study is to compare and validate several preoperative scores for predicting outcomes following spine tumor resection.

Summary Of Background Data: Preoperative risk assessment for patients undergoing spinal tumor resection remains challenging. At present, few risk assessment tools have been validated in this high-risk population.

Methods: The 2008 to 2014 National Surgical Quality Improvement database was used to identify all patients undergoing surgical resection of spinal tumors, stratified as extradural, intradural extramedullary, and intramedullary based on CPT codes. American Society of Anesthesiologists (ASA) score, modified Charlson Comorbidity Index (CCI), and modified Frailty Index (mFI) were computed. A binary logistic regression model was used to explore the relationship between these variables and postoperative outcomes, including mortality, major and minor adverse events, and hospital length of stay (LOS). Other significant variables such as demographics, operative time, and tumor location were controlled for in each model.

Results: Two thousand one hundred seventy patients met the inclusion criteria. Higher CCI scores were independent predictors of mortality (OR = 1.24, 95% CI: 1.14-1.36, P < 0.001), major adverse events (OR = 1.07, 95% CI: 1.01-1.31, P = 0.018), minor adverse events (OR = 1.15, 95% CI: 1.10-1.20, P < 0.001), and prolonged LOS (OR = 1.14, 95% CI: 1.09-1.19, P < 0.001). Patients' mFI scores were significantly associated with mortality and LOS, but not major or minor adverse events. ASA scores were not associated with any outcome metric when controlling for other variables.

Conclusion: The CCI demonstrated superior predictive capacity compared with mFI and ASA scores and may be valuable as a preoperative risk assessment tool for patients undergoing surgical resection of spinal tumors. The validation of assessment scores is important for preoperative risk stratification and improving outcomes in this high-risk group.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002970DOI Listing
July 2019

The Use of Spectroscopy Handheld Tools in Brain Tumor Surgery: Current Evidence and Techniques.

Front Surg 2019 29;6:30. Epub 2019 May 29.

Department of Neurosurgery, Mount Sinai Health System, Icahn School of Medicine at Mount Sinai, New York, NY, United States.

The fundamental principle in the operative treatment of brain tumors involves achieving maximal safe resection in order to improve postoperative outcomes. At present, challenges in visualizing microscopic disease and residual tumor remain an impediment to complete tumor removal. Spectroscopic tools have the theoretical advantage of accurate tissue identification, coupled with the potential for manual intraoperative adjustments to improve visualization of remaining tumor tissue that would otherwise be difficult to detect. The current evidence and techniques for handheld spectroscopic tools in surgical neuro-oncology are explored here.
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http://dx.doi.org/10.3389/fsurg.2019.00030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6548876PMC
May 2019

Coagulation Laboratory Testing Is Predictive of Wound Complications Following Microdiscectomy.

Global Spine J 2019 Apr 31;9(2):138-142. Epub 2018 Jul 31.

University of Utah, Salt Lake City, UT, USA.

Study Design: Retrospective review.

Objective: To determine whether abnormal preoperative testing is associated with postoperative complications in patients undergoing a microdiscectomy.

Methods: Patients undergoing a microdiscectomy between 2006 and 2013 were identified in the National Surgical Quality Improvement Program database based on appropriate current procedural terminology coding. Thirty-day postoperative complications were analyzed in addition to patient demographics, comorbidities, and abnormal preoperative laboratory values. A series of over 650 univariate analyses to determine which independent variables to include for each complication were completed. Based on those analyses, 12 logistic regression models were built, one for each specific complication. Each model adjusted for age, gender, comorbidities, American Society of Anesthesiologists classification, as well as operative time.

Results: A total of 5947 patients undergoing a microdiscectomy were included in the study. Abnormal preoperative international normalized ratio (odds ratio [OR] = 5.85, < .05) was associated with any wound infection, superficial or deep, and abnormal partial thromboplastin time was significantly associated with wound dehiscence (OR = 6.80, < .05). Postoperative urinary tract infections were associated with abnormal preoperative hematocrit (OR = 8.00, < .05). None of the identified preoperative labs were independently associated with pulmonary embolism, organ space surgical site infections, or intubation.

Conclusions: Abnormal preoperative coagulation labs were significantly associated with postoperative wound complications. However, the majority of tests were not associated with adverse events following microdiscectomy. Further study is necessary to conclude whether these tests provide information that can modify perioperative management and whether widespread testing is cost-effective.
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http://dx.doi.org/10.1177/2192568218764677DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6448192PMC
April 2019

Management of Femoral Defects Greater Than 5 cm Following Open Femur Fractures: A 12-Year Retrospective Review.

J Surg Orthop Adv Fall 2018;27(3):203-208

Vanderbilt University Medical Center, Nashville, Tennessee; e-mail:

This study sought to evaluate the outcomes of patients with osseous defects exceeding 5 cm following open femur fractures. Size of the osseous defect, method of internal fixation (plate vs. intramedullary nail), patient demographics, medical comorbidities, and surgical complications were collected. Twenty-seven of the 832 open femur fracture patients had osseous defects exceeding 5 cm. Mean osseous defect size was 8 cm, and each patient had an average of four operations including initial debridement. Average time from injury to bone grafting was 123.7 days. The overall complication rate was 48.1% ( = 13). The most common complications were infection (26.0%, = 7) and nonunion (41.0%, = 11). Smoking, diabetes, ASA score, and defect size did not independently increase the risk of a complication. Management of open femur fractures with osseous defects greater than 5 cm is associated with high complication rate, driven primarily by infection and nonunion. (Journal of Surgical Orthopaedic Advances 27(3):203-208, 2018).
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February 2019

Prevalence of large vessel occlusion in patients presenting with acute ischemic stroke: a 10-year systematic review of the literature.

J Neurointerv Surg 2019 Mar 10;11(3):241-245. Epub 2018 Nov 10.

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

Background: Accurate assessment of the prevalence of large vessel occlusion (LVO) in patients presenting with acute ischemic stroke (AIS) is critical for optimal resource allocation in neurovascular intervention.

Objective: To perform a systematic review of the literature in order to identify the proportion of patients with AIS presenting with LVO on image analysis.

Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in order to identify studies reporting LVO rates for patients presenting with AIS. Studies that included patients younger than 18 years, were non-clinical, or did not report LVO rates in the context of a consecutive AIS series were excluded. Characteristics regarding presentation, diagnosis, and LVO classification were recorded for each paper.

Results: Sixteen studies, spanning a total of 11 763 patients assessed for stroke, were included in the qualitative synthesis. The majority (10/16) of articles reported LVO rates exceeding 30% in patients presenting with AIS. There was substantial variability in the LVO definitions used, with nine unique classification schemes among the 16 studies. The mean prevalence of LVO was 31.1% across all studies, and 29.3% when weighted by the number of patients included in each study.

Conclusions: Despite the wide variability in LVO classification, the majority of studies in the last 10 years report a high prevalence of LVO in patients presenting with AIS. These rates of LVO may have implications for the volume of patients with AIS who may benefit from endovascular therapy.
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http://dx.doi.org/10.1136/neurintsurg-2018-014239DOI Listing
March 2019

Effect of Resident and Fellow Involvement in Adult Spinal Deformity Surgery.

World Neurosurg 2019 Feb 1;122:e759-e764. Epub 2018 Nov 1.

Department of Neurological Surgery, Vanderbilt University, Nashville, Tennessee, USA; Orthopaedics of Steamboat Springs, Steamboat Springs, Colorado, USA.

Background: Adult spinal deformity (ASD) operations are complex and often require a multisurgeon team. Simultaneously, it is the responsibility of academic spine surgeons to train future complex spine surgeons. Our objective was to assess the effect of resident and fellow involvement (RFI) on ASD surgery in 4 areas: 1) perioperative outcomes, 2) length of stay (LOS), 3) discharge status, and 4) complications.

Methods: Adults undergoing thoracolumbar spinal deformity correction from 2008 to 2014 were identified in the National Surgical Quality Improvement Program database. Cases were divided into those with RFI and those with attendings only. Outcomes were operative time, transfusions, LOS, discharge status, and complications. Univariate and multivariable regression modeling was used. Covariates included preoperative comorbidities, specialty, and levels undergoing instrumentation.

Results: A total of 1471 patients underwent ASD surgery with RFI in 784 operations (53%). After multivariable regression modeling, RFI was independently associated with longer operations (β = 66.01 minutes; 95% confidence interval [CI], 35.82-96.19; P < 0.001), increased odds of transfusion (odds ratio, 2.80; 95% CI, 1.81-4.32; P < 0.001), longer hospital stay (β = 1.76 days; 95% CI, 0.18-3.34; P = 0.030), and discharge to an inpatient rehabilitation or a skilled nursing facility (odds ratio, 2.02; 95% CI, 1.34-3.05; P < 0.001). However, RFI was not associated with any increase in major or minor complications.

Conclusion: RFI in ASD surgery was associated with increased operative time, the need for additional transfusions, longer LOS, and nonhome discharge. However, no increase in major, minor, or severe complications occurred. These data support the continued training of future deformity and complex spine surgeons without fear of worsening complications; however, areas of improvement exist.
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http://dx.doi.org/10.1016/j.wneu.2018.10.135DOI Listing
February 2019