Publications by authors named "Nima Alan"

46 Publications

Intraparenchymal hematoma and intraventricular catheter placement using robotic stereotactic assistance (ROSA): A single center preliminary experience.

J Clin Neurosci 2021 Sep 2;91:391-395. Epub 2021 Aug 2.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.

Background: Large supratentorial intraparenchymal hemorrhages are managed emergently with image-guided catheters that aim to minimize injury to surrounding parenchyma. Robotic assistance may offer advantages for stereotactic guidance and placement of such catheters. We describe our center's experience with minimally invasive ROSA-assisted intraventricular and intraparenchymal hemorrhage catheter placement and delineate its safety and outcomes.

Methods: A retrospective analysis was performed including all patients with intraparenchymal hematoma that underwent ROSA-assisted intraparenchymal and intraventricular catheter placement at the University of Pittsburgh Medical Center between 2017 and 2019. All patients received tissue plasminogen activator (tPA) through the intraparenchymal catheter. We performed a manual chart review of these patients. Pertinent clinical and radiological characteristics and patient outcomes were recorded and analyzed. Catheter trajectory was independently quantified and analyzed by two independent reviewers. Error between the planned trajectory and final position was calculated and analyzed.

Results: Four patients (2 males and 2 females, mean age of 64 years) with deep brain large volume intraparenchymal hemorrhages were treated with catheter evacuation with robotic assistance. For 2 of the 4 patients, thin-cut CT imaging allowed for the real trajectory of the catheter to be compared to the targeted trajectory to calculate error. The mean error of catheter placement was 3.48 mm. ROSA-assisted catheter placement achieved up to 95% reduction of intraparenchymal hematoma volume with a statistically significant decrease following catheter drainage (pre- 51.8 ± 19.1 cc vs. post- 13.0 ± 14.4; p < 0.01).

Conclusion: Robotic stereotactic assistance offers a safe and sufficiently accurate technique for intraparenchymal hematoma and intraventricular catheter placement.
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http://dx.doi.org/10.1016/j.jocn.2021.04.006DOI Listing
September 2021

Does Variceal Drainage Affect Arteriovenous Malformation Obliteration and Hemorrhage Rates After Stereotactic Radiosurgery? A Case-Matched Analysis.

Neurosurgery 2021 Sep;89(4):680-685

Department of Neurological Surgery and Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: Stereotactic radiosurgery (SRS) is widely accepted as a minimally invasive alternative to surgery in the management of arteriovenous malformations (AVMs). Dilated AVM outflow veins or varices may be caused by high-flow or partial outflow obstruction, which may increase the risk of a hemorrhage before or after SRS.

Objective: To compare the obliteration and hemorrhage risks in patients with and without AVM varices (AVMv).

Methods: From our prospective database of 1012 AVM patients who underwent Gamma Knife® (Elekta) SRS, we identified 103 patients with AVMv, and 847 patients without varices. The median follow-up was 52 mo. Balancing variable score matching was performed to compare obliteration and hemorrhage rates between the 2 groups.

Results: Obliteration rates in the AVMv group were 38% at 3 yr, 65% at 4 yr, and 70% at 5 yr. Patients with an AVMv had no difference in the final obliteration rate compared to patients who did not have variceal drainage (P = .35). Actuarial hemorrhage after SRS in the matched patients with AVMv was 4.9%, 13%, and 13.7%, at 1, 3, and 5 yr, respectively. The rate of hemorrhage in the group with no varix was 2.9%, 5.4%, and 9.1% at 1, 3, and 5 yr, respectively (P = .14).

Conclusion: The presence of AVM variceal venous drainage did not affect the obliteration rate and did not confer a higher risk of a subsequent hemorrhage both before and after SRS.
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http://dx.doi.org/10.1093/neuros/nyab256DOI Listing
September 2021

Incidence of adjacent-segment surgery following stand-alone lateral lumbar interbody fusion.

J Neurosurg Spine 2021 Jun 18:1-5. Epub 2021 Jun 18.

Objective: Adjacent-segment disease (ASD) requiring operative intervention is a relatively common long-term consequence of lumbar fusion surgery. Although the incidence of ASD requiring reoperation is well described for traditional posterior lumbar approaches (2.5%-3.9% per year), it remains poorly characterized for stand-alone lateral lumbar interbody fusion (LLIF). In this study, the authors report their institutional experience with ASD requiring reoperation after LLIF over an extended follow-up period of 4 years.

Methods: Medical records were reviewed for 276 consecutive patients who underwent stand-alone LLIF by a single surgeon for degenerative spinal disorders. Inclusion criteria (single-stage, stand-alone LLIF without posterior supplementation, with no prior lumbar instrumentation, and a minimum of 4 years of follow-up) were met by 182 patients, who were analyzed for operative ASD incidence (per-year rate), demographics, and Oswestry Disability Index (ODI) score. Operative ASD was strictly defined as new-onset pathology following index surgery at directly adjacent levels to the prior construct. Operative, rather than symptomatic or radiographic, ASD was analyzed to provide a consistent and impactful endpoint while avoiding retrospective diagnosis.

Results: The study cohort of 182 patients had an operative ASD rate of 3.3% (n = 6 procedures) over 4 years of follow-up, for an incidence on Kaplan-Meier survival analysis of 0.88% (95% CI 0.67%-1.09%) per year. In comparing patients with operative ASD with those without, there were no significant differences in mean age (53.7 vs 56.2 years), male sex (33.3% vs 44.9%), smoking status (16.7% vs 25.0%), or number of levels fused (mean 1.33 vs 1.46). The operative ASD cohort had a greater mean BMI (37.3 vs 30.2, p < 0.01). Operative ASD patients had lower baseline ODI scores (33.8 vs 48.3, p = 0.02); however, no difference was observed in ODI at 6 weeks (34.0 vs 39.0) or 3 months (16.0 vs 32.8) postoperatively.

Conclusions: The incidence of ASD in LLIF for degenerative lumbar etiologies in this cohort was 0.88% (95% CI 0.67%-1.09%) per year. Meanwhile, the reported reoperation rates for ASD in posterior spinal approaches was 2.5% to 3.9% per year, which implies that LLIF may be preferable for well-selected patients.
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http://dx.doi.org/10.3171/2020.12.SPINE201218DOI Listing
June 2021

Load-Sharing Classification Score as Supplemental Grading System in the Decision-Making Process for Patients With Thoracolumbar Injury Classification and Severity 4.

Neurosurgery 2021 Aug;89(3):428-434

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: Patients with Thoracolumbar Injury Classification and Severity (TLICS) score of 4 fall into a gray zone between surgical and conservative management. The integrity of posterior ligamentous complex (PLC) evaluated by magnetic resonance imaging (MRI) contributes to surgical decision-making. Load-sharing classification (LSC) may provide a modifier to further guide decision-making in these patients.

Objective: To evaluate associations between LSC score and MRI acquisition, compromise of PLC on MRI, and surgical intervention in TLICS 4 patients.

Methods: A cohort of 111 neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was evaluated. LSC score was determined based on degree of comminution (1-3), apposition (1-3), and kyphosis (1-3), total composite score of 3 to 9.

Results: Overall, 44 patients underwent MRI, 15 had PLC injury, and 32 (28.8%) underwent surgery. LSC score was higher in patients who had an MRI (median 6 vs 3, P < .001) and patients who had surgery (median 7 vs 4, P < .001). In univariate logistic regression, LSC score was associated with MRI acquisition (odds ratio [OR] 1.7; 1.32-2.12; P < .001), presence of PLC injury on MRI (OR 1.5; 1.2-2.0; P = .002) and, in multivariate logistic regression, undergoing surgical intervention (OR 3.7; 2.3-5.9; P < .001), independent of MRI or PLC injury.

Conclusion: LSC score in neurologically intact patients with isolated thoracolumbar burst fracture with TLICS 4 was independently associated with operative intervention. The application of LSC may further guide decision-making in this patient group.
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http://dx.doi.org/10.1093/neuros/nyab179DOI Listing
August 2021

Safety and Efficacy of Balloon Kyphoplasty for Vertebral Fractures With Posterior Wall Disruption.

Int J Spine Surg 2021 Apr 1;15(2):353-358. Epub 2021 Apr 1.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: Percutaneous balloon kyphoplasty (BK) is widely accepted as both a safe and effective method for the treatment of symptomatic benign vertebral compression fractures (VCFs) of the thoracic and lumbar spines. A disruption in the posterior wall of the affected vertebra is often considered to be a relative or an absolute contraindication to BK. This study was performed to determine the safety as well as the efficacy of BK for vertebral body compression fractures associated with posterior wall disruption.

Methods: This was a retrospective, nonrandomized clinical cohort investigation of patients with VCF and posterior wall disruption treated with BK between 2010 and 2018. All cases were performed using a bipedicular technique. Each case was examined for cement leakage, anterior vertebral body height restoration, improvement in pain (determined by VAS) from baseline and 6-week postprocedure, and clinical sequelae from cement leakage.

Results: Ninety-eight consecutive patients with 157 VCF levels who underwent BK were evaluated. There was a significant improvement in anterior vertebral height, vertebral wedge angle, and local kyphotic angle in all cases. The mean preoperative VAS improved from 8.7 preprocedure to 2.5 postprocedure ( = .001). There were 14 (9%) cases with asymptomatic cement leakage outside of the vertebral body, and no patients experienced postprocedure neurological symptoms at the 6-week follow up.

Conclusions: BK in the setting of posterior wall disruption was found to be a safe and highly effective treatment for patients with benign compression fractures. Posterior wall disruption should not be considered an absolute contraindication to BK.
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http://dx.doi.org/10.14444/8046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8059384PMC
April 2021

Evaluation of free-hand screw placement in cervical, thoracic, and lumbar spine by neurosurgical residents.

Clin Neurol Neurosurg 2021 May 3;204:106585. Epub 2021 Mar 3.

Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States. Electronic address:

Background: Knowledge of free-hand screw technique remains critical to adequately train neurosurgical residents. The purpose of this study was to evaluate the accuracy of screw placement via the free-hand technique in lumbar, thoracic, and cervical spine by neurosurgical residents completing an enfolded spine fellowship.

Methods: Medical records of all patients who underwent free-hand screw placement at all spinal levels over a 6-month period by senior neurosurgical residents enrolled in an in-folded spine fellowship were retrospectively reviewed. Postoperative CT images were assessed for presence and direction of cortical breach.

Results: Twenty-six patients underwent 162 free-hand screw placements. The most commonly placed screws were cervical lateral mass screws (n = 69), thoracic (n = 41), and lumbar pedicle screws (n = 41). The most common indication for surgery was deformity (n = 22), followed by infection (n = 2) and trauma (n = 2). Fifty-five breaches were identified in 44 (27 %) screws placed in 21 patients (81 %). Anterior breach was identified in 22 cases (40.0 %), lateral in 12 (23.6 %), superior in 7 (12.7 %), and inferior in 7 (12.7 %), and medial in 6 (10.9 %). The most common level of breach was observed in cervical lateral mass screws (n = 19, 43 %) and least common in C2 pars screws (n = 1, 2%). With an average length of follow up of 12.1 ± 7.7 months of follow-up, no clinical sequalae of screw breach was observed.

Conclusions: Despite the high prevalence of screw breach using the free-hand technique by neurosurgical residents, the absence of clinical sequelae implies safety and emphasizes the importance of early exposure to this technique during neurosurgical residency training.
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http://dx.doi.org/10.1016/j.clineuro.2021.106585DOI Listing
May 2021

The utility of routine head CT for hemorrhage surveillance in post-craniotomy patients undergoing anticoagulation for venous thromboembolism.

J Clin Neurosci 2021 Mar 15;85:78-83. Epub 2021 Jan 15.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States. Electronic address:

Anticoagulation for postoperative venous thromboembolism (VTE) may infer a higher risk of intracranial hemorrhage. We treat patients with VTE using slowly titrating intravenous heparin drip without bolus. When PTT is greater than 60 s, a head CT is obtained to monitor for the development of a intracranial hemorrhage before transition to oral anticoagulation. We evaluated the utility of routine surveillance head CT to monitor for intracranial hemorrhage during anticoagulation. This is a case series of neurosurgical patients in an academic quaternary hospital who developed a VTE after cranial procedures between 2007 and 2017. Over 11,000 patients were screened for the study. Patients' demographics data, surgical indication, PTT at the time of surveillance CT head, surveillance CT head findings, and patient's clinical course were reviewed. A total of 83 patients were included. Three patients (3.6%) developed a new subclinical hemorrhage on CT head imaging while on heparin drip. Interval CT head showed stable hemorrhage in all patients. Heparin drip was stopped in two patients and they both progressed from DVT to pulmonary embolism: one patient died due to cardiac arrest, the other patient was transitioned to oral anticoagulation. In the third patient heparin drip was continued uneventfully and transitioned to oral anticoagulation with no further clinical sequalae. Surveillance CT while on heparin drip for VTE management detected subclinical intracranial hemorrhage in a small subset of patients. Patients whose anticoagulation was stopped had progression of VTE. Undertreatment of VTE in the presence of subclinical hemorrhage may lead to significant morbidity and mortality.
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http://dx.doi.org/10.1016/j.jocn.2020.12.010DOI Listing
March 2021

Inter-facility transfer of patients with traumatic intracranial hemorrhage and GCS 14-15: The pilot study of a screening protocol by neurosurgeon to avoid unnecessary transfers.

J Clin Neurosci 2020 Nov 15;81:246-251. Epub 2020 Oct 15.

University of Pittsburgh Medical Center, Department of Neurological Surgery, Pittsburgh, PA, United States.

We sought to evaluate feasibility and cost-reduction potential of a pilot screening program involving neurosurgeon tele-consultation for inter-facility transfer decisions in TBI patients with GCS 14-15 and abnormal CT head at a community hospital. The authors performed a retrospective comparative analysis of two patient cohorts during the pilot at a large hospital system from 2015 to 2017. In "screened" patients (n = 85), images and examination were reviewed remotely by a neurosurgeon who made recommendations regarding transfer to a level 1 trauma center. In the "unscreened" group (n = 39), all patients were transferred. Baseline patient characteristics, outcomes, and costs were reviewed. Patient demographics were similar between cohorts. Traumatic subarachnoid hemorrhage was more common in screened patients (29.4% vs 12.8%, P = 0.02). The presence of midline shift >5 mm was comparable between groups. Among screened patients, 5 were transferred (5.8%) and one required evacuation of chronic subdural hematoma. In unscreened patients, 7 required evacuation of subdural hematoma. None of the screened patients who were not transferred deteriorated. Screened patients had significantly reduced average total cost compared to unscreened patients ($2,003 vs. $4,482, P = 0.03) despite similar lengths of stay (2.6 vs. 2.7 days, P = 0.85). In non-surgical patients, costs were less in the screened group ($2,025 vs. $2,939), although statistically insignificant (P = 0.38). In this pilot study, remote review of images and examination by a neurosurgeon was feasible to avoid unnecessary transfer of patients with traumatic intracranial hemorrhage and GCS 14-15. The true potential in cost-reduction will be realized in system-wide large-scale implementation.
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http://dx.doi.org/10.1016/j.jocn.2020.09.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7560640PMC
November 2020

Longitudinal Survey of Trainee Case Log Entry for Carotid Endarterectomy: Trends in Neurologic, General, and Vascular Surgery.

World Neurosurg 2021 02 2;146:e658-e663. Epub 2020 Nov 2.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. Electronic address:

Background: Multiple surgical specialties perform carotid endarterectomy (CEA). As indications for CEA narrows, neurosurgery residents are less exposed to this procedure. This study aims to determine trends in CEA training among graduating trainees in neurosurgery and compare these to general and vascular surgery.

Methods: ACGME case log reports were retrospectively reviewed from 2013 to 2019 for neurologic, general, and vascular surgery residencies and vascular surgery fellowship. These annual reports contain the mean number of logged cases for graduating trainees and their level of participation. We analyzed trends in logged cases over the study period and compared mean number of logged cases between specialties and their respective required minimum numbers.

Results: Neurosurgery residents (13.5 ± 0.76) performed significantly more CEAs than their counterparts in general surgery (9.4 ± 0.34, P < 0.01) but less in integrated vascular surgery (57.7 ± 0.88) and vascular surgery fellowship (47.9 ± 0.79, both P < 0.001). The only statistically significant change over the study period was a decline in mean number of cases logged by general surgery residents at -0.4 cases/year (P < 0.001). Trainees in all specialties reported around twice as many cases as the respective Accreditation Council for Graduate Medical Education required minimum numbers. Neurosurgery residents demonstrated increasing participation as lead surgeons by 0.7 cases/year (P = 0.04) and a concurrent decline as senior surgeons by 1.4 cases/year (P < 0.01).

Conclusions: Neurosurgery residents exceeded their minimum requirements for CEA, with increasing trend in higher level of participation. But neurosurgery residents' exposure to this procedure was far less significant than their colleagues in vascular surgery, a gap that may widen over time and should be addressed proactively.
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http://dx.doi.org/10.1016/j.wneu.2020.10.145DOI Listing
February 2021

Preoperative Chronic Opiate Use and Patient Reported Outcomes Following Adult Spinal Reconstructive Surgery.

World Neurosurg 2020 11 19;143:e166-e171. Epub 2020 Jul 19.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. Electronic address:

Background: Preoperative chronic narcotic use has been linked to poor outcomes after surgery for degenerative spinal disorders in the form of lower health-related quality of life scores, higher revision rates, increased infections, lower likelihood of return to work, and higher 90-day readmission rates. This study evaluated the impact of preoperative chronic narcotic use on patient reported outcome measures following adult spinal reconstructive surgery.

Methods: Patients who underwent adult spinal reconstructive surgery over 2 years at our institution were identified from a prospectively maintained spine registry. These patients were grouped into chronic opiate users as defined by a 6-month duration of use with a minimum morphine equivalent dose of 30 mg/day. Patient reported outcome measures were collected prospectively.

Results: Of 140 patients included for analysis, 30 (21.4%) patients were categorized as chronic opiate users. No differences were identified in mean preoperative patient reported outcome measures, including Oswestry Disability Index, health state, visual analog scale, and EQ-5D indices. At both 6 weeks and 6 months postoperatively, patients in the opiate group demonstrated significantly worse mean visual analog scale back pain scores relative to the nonopiate group. At 6 months postoperatively and at the last known clinical follow-up, Oswestry Disability Index scores were higher in the opiate group.

Conclusions: Chronic opiate use before adult spinal reconstructive surgery was associated with worse pain and disability following intervention. Further work is needed to understand the role of opiate weaning as part of a larger prehabilitation strategy for adult spinal reconstructive surgery.
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http://dx.doi.org/10.1016/j.wneu.2020.07.084DOI Listing
November 2020

Coronavirus Disease 2019 (COVID-19) and Neurosurgery Residency Action Plan: An Institutional Experience from the United States.

World Neurosurg 2020 11 18;143:e172-e178. Epub 2020 Jul 18.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. Electronic address:

Background: The current pandemic crisis, caused by a novel human coronavirus named severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), has forced a dramatic change in our society. A key portion of the medical work force on the frontline is composed of resident physicians. Thus, it becomes imperative to create an adequate and effective action plan to restructure this valuable human resource amid the SARS-CoV2 pandemic. We sought to describe a comprehensive approach taken by a Neurosurgery Department in quaternary care academic institution in the United States of America amid the SARS-CoV2 pandemic focused in resident training and support.

Objective: To describe a comprehensive approach taken by a Neurosurgery Department in quaternary care academic institution in the United States of America amid the SARS-CoV2 pandemic focused on resident training and support.

Results: A restructuring of the Neurosurgery Department at our academic institution was performed focused on decreasing their risk of infection/exposure and transmission to others, while minimizing negative consequences in the training experience. An online academic platform was built for resident education, guidance, and support, as well as continue channel for pandemic update by the department leadership.

Conclusions: The SARS-CoV2 pandemic constitutes a global health emergency full of uncertainty. Treatment, scope, duration, and economic burden forced a major restructuring of our medical practice. In this regard, academic institutions must direct efforts to diminish further negative impact in the training and education of the upcoming generation of physicians, including those currently in medical school. Perhaps the only silver lining in this terrible disruption will be greater appreciation of the role of current health care providers and educators, whose contributions to our society are often neglected or unrecognized.
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http://dx.doi.org/10.1016/j.wneu.2020.07.080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368409PMC
November 2020

Relationship Between Preoperative Opioid Use and Postoperative Pain in Patients Undergoing Minimally Invasive Stand-Alone Lateral Lumbar Interbody Fusion.

Neurosurgery 2020 Jun 11. Epub 2020 Jun 11.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Background: Opioid use in the management of pain secondary to spinal disorders has grown significantly in the United States. However, preoperative opioid use may complicate recovery in patients undergoing surgical procedures.

Objective: To test our hypothesis that prolonged preoperative opioid use may lead to poorer patient outcomes following minimally invasive stand-alone lateral lumbar interbody fusion (LLIF) for lumbar degenerative disc disease.

Methods: A consecutive series of patients from a single institution undergoing LLIF between December 2009 and January 2017 was retrospectively analyzed. Patients were categorized according to the presence or absence of prescribed preoperative opioid use for at least 3 mo. Outcomes included the Oswestry Disability Index (ODI), visual analog scale (VAS), and Short Form 36 Physical and Mental Summary Scores (SF-36 PCS, SF-36 MCS).

Results: Of 107 patients, 57 (53.1%) were prescribed preoperative opioids. There was no significant difference in preoperative ODI, VAS score, SF-36 PCS, or SF-36 MCS between opioid use groups. Mean postoperative ODI was greater in patients with preoperative opioid use at 41.7 ± 16.9 vs 22.2 ± 16.0 (P = .002). Mean postoperative VAS score was greater in patients prescribed preoperative opioids, while magnitude of decrease in VAS score was greater in opioid-naïve patients (P = .001). Postoperative SF-36 PCS was 33.1 ± 10.6 in the opioid use group compared to 43.7 ± 13.1 in the nonuse group (P = .001).

Conclusion: Following LLIF, patients prescribed preoperative opioids had increased postoperative lumbar pain, disability, and subjective pain.
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http://dx.doi.org/10.1093/neuros/nyaa207DOI Listing
June 2020

Impact of endplate-implant area mismatch on rates and grades of subsidence following stand-alone lateral lumbar interbody fusion: an analysis of 623 levels.

J Neurosurg Spine 2020 Mar 6:1-5. Epub 2020 Mar 6.

Objective: Stand-alone lateral lumbar interbody fusion (LLIF) is a useful minimally invasive approach for select spinal disorders, but implant subsidence may occur in up to 30% of patients. Previous studies have suggested that wider implants reduce the subsidence rate. This study aimed to evaluate whether a mismatch of the endplate and implant area can predict the rate and grade of implant subsidence.

Methods: The authors conducted a retrospective review of prospectively collected data on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 surgical levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria. Thirty patients had radiographic evidence of implant subsidence. The endplates above and below the implant were measured.

Results: A total of 30 patients with implant subsidence were identified. Of these patients, 6 had Marchi grade 0, 4 had grade I, 12 had grade II, and 8 had grade III implant subsidence. There was no statistically significant correlation between the endplate-implant area mismatch and subsidence grade or incidence. There was also no correlation between endplate-implant width and length mismatch and subsidence grade or incidence. However, there was a strong correlation between the usage of the 18-mm-wide implants and the development of higher-grade subsidence (p = 0.002) necessitating surgery. There was no significant association between the degree of mismatch or Marchi subsidence grade and the presence of postoperative radiculopathy. Of the 8 patients with 18-mm implants demonstrating radiographic subsidence, 5 (62.5%) required reoperation. Of the 22 patients with 22-mm implants demonstrating radiographic subsidence, 13 (59.1%) required reoperation.

Conclusions: There was no correlation between endplate-implant area, width, or length mismatch and Marchi subsidence grade for stand-alone LLIF. There was also no correlation between either endplate-implant mismatch or Marchi subsidence grade and postoperative radiculopathy. The data do suggest that the use of 18-mm-wide implants in stand-alone LLIF may increase the risk of developing high-grade subsidence necessitating reoperation compared to the use of 22-mm-wide implants.
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http://dx.doi.org/10.3171/2020.1.SPINE19776DOI Listing
March 2020

Complications After 3- and 4-Level Anterior Cervical Diskectomy and Fusion.

World Neurosurg 2019 Oct 16;130:e1105-e1110. Epub 2019 Jul 16.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: Anterior cervical diskectomy and fusion (ACDF) is a standard surgical procedure used widely in the treatment of degenerative cervical spine conditions. Although the safety and effectiveness of single-level ACDF is well supported in the literature, reports of multilevel ACDF are sparse and present mixed results. There is concern for greater complications with increasing levels of fusion given the increased complexity, procedure duration, and invasiveness of multilevel ACDF.

Methods: In this retrospective review, we report complications data for 105 adult neurosurgical patients who underwent elective multilevel ACDF at a single institution by a single surgeon between 2004 and 2016.

Results: Fifty-four patients underwent 3-level ACDF and 51 patients underwent 4-level ACDF with a mean follow-up of 2.7 ± 1.9 years. Although patients with 4-level fusion were more likely than those with 3-level fusion to have estimated blood loss ≥100 mL (P = 0.04), we found no significant differences in other peri- and postoperative complications, need for revision, and presence of symptoms at the time of last follow-up between groups.

Conclusions: This study suggests that 4-level ACDF is not necessarily associated with a greater number of or more severe complications than 3-level ACDF.
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http://dx.doi.org/10.1016/j.wneu.2019.07.099DOI Listing
October 2019

Retrospective Multicenter Assessment of Rod Fracture After Anterior Column Realignment in Minimally Invasive Adult Spinal Deformity Correction.

World Neurosurg 2019 Oct 21;130:e400-e405. Epub 2019 Jun 21.

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

Background: Anterior column realignment (ACR) was developed as a minimally invasive method for treating sagittal imbalance. However, rod fracture (RF) rates associated with ACR are not known. Our objective was to assess the rate of and risk factors for RF following ACR in deformity correction surgery.

Methods: We conducted a retrospective multicenter review of patients with adult spinal deformity (ASD) who underwent ACR for deformity correction. ASD was defined as coronal Cobb angle ≥20°, pelvic incidence-lumbar lordosis >10°, sagittal vertical axis ≥5 cm, pelvic tilt ≥25°, or thoracic kyphosis ≥60°. Inclusion criteria were ASD, age >18 years, use of ACR, and development of RF or full radiographs obtained at least 1 year after surgery that did not demonstrate RF.

Results: Ninety patients were identified, with mean follow-up of 2.3 ± 1.4 years (age, 64.1 ± 9.4; 54 [60%] women). The most common ACR location was L3/4 (42 cases; 47%). Mean fusion length was 7.5 ± 3.6 levels. Four (4.4%) of 90 patients developed RF within 12 months of surgery. RF occurred adjacent to ACR in all cases; RF was not associated with focal correction (P = 0.49), rod material (P = 0.8), degree of correction (P > 0.07), or interbody at L5/S1 (P = 0.06). RF was associated with longer fusion constructs in univariate (P = 0.002) and multivariate (P = 0.03) analyses.

Conclusions: RF occurred in 4.4% of patients with ASD who underwent ACR with a minimum of 1-year follow-up. RF was not associated with focal correction but appears to be associated with global correction and extent of fixation.
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http://dx.doi.org/10.1016/j.wneu.2019.06.096DOI Listing
October 2019

Perioperative Neurological Complications Following Anterior Cervical Discectomy and Fusion: Clinical Impact on 317,789 Patients from the National Inpatient Sample.

World Neurosurg 2019 Aug 10;128:e107-e115. Epub 2019 Apr 10.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA. Electronic address:

Background: Perioperative neurologic complication after an anterior cervical discectomy and fusion (ACDF) is uncommon but may have significant clinical consequences.

Objective: We aim to estimate the incidence of perioperative neurologic complications, identify their risk factors, and evaluate their impact on morbidity and mortality after ACDF.

Methods: ACDF cases (n = 317,789 patients) were extracted from the National Inpatient Sample between 1999 and 2011. Based on their Elixhauser-van Walraven score (VWR), patients were classified as low (VWR < 5), moderate (5-14), or high risk (>14) for surgery. The primary outcome was perioperative neurologic complications. Secondary outcomes included morbidity (hospital length of stay >14 days or discharge disposition to a location other than home) and in-hospital mortality.

Results: The rate of perioperative neurologic complications, morbidity, and mortality after ACDF was 0.4%, 8.4%, and 0.1%, respectively. Perioperative neurologic complications were highly associated with in-house morbidity (odds ratio [OR], 3.7 [3.1-4.4]) and mortality (OR, 8.0 [4.1-15.5]). The strongest predictors for perioperative neurologic complications were moderate- (OR, 3.1 [2.6-3.7]) and high-risk VWR (OR, 5.4 [3.3-8.9]), postoperative hematoma/seroma formation (OR, 5.4 [3.9-7.4]), and obesity (OR, 1.9 [1.6-2.3]). The rate of perioperative neurologic complications increased from 0.2% to 0.7% from 1999 to 2011, which was temporally associated with the rise in moderate- (P = 0.002) and high-risk patients (P = 0.001) undergoing ACDF.

Conclusions: Perioperative neurologic complications are independent predictors of in-hospital morbidity and mortality after ACDF. Both morbidity and perioperative neurologic complications have increased between 1999 and 2011, which may be due, in part, to increasing numbers of moderate- and high-risk patients undergoing ACDF.
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http://dx.doi.org/10.1016/j.wneu.2019.04.037DOI Listing
August 2019

Citation analysis of the most influential articles on traumatic spinal cord injury.

J Spinal Cord Med 2020 01 14;43(1):31-38. Epub 2019 Feb 14.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

We conducted a citation analysis in order to catalog and pay tribute to the 100 most influential clinical research articles in traumatic spinal cord injury. The Thomson Reuters Web of Science was searched in a two-step process without time period limitations. Review articles were excluded. In the first stage of data extraction, a Boolean query was used to identify the top 100 most cited clinical papers on traumatic spinal cord injury. One hundred and seven keywords were manually chosen and extracted from titles and abstracts. A second Boolean query used these keywords to broaden search results. The top 100 articles from this second stage search comprised the final list. For each article, measures evaluated were number of citations, average number of citations per year, time elapsed before first citation, and time elapsed until the year in which each article received its respective highest number of citations in a one-year period. 119,991 articles were found in the second stage search. The top 100 most cited articles meeting inclusion criteria were identified within the first 2,104 results. Archives of Physical Medicine and Rehabilitation was the most represented journal, with 20 of the top 100 articles. The top 100 list averaged 255 citations per article. The most highly cited article was the NASCIS 2 trial by Bracken ., cited 1500 times, which investigated the efficacy of methylprednisolone or naloxone for spinal cord injury. Clinical research in traumatic spinal cord injury has grown over time, expanding to encompass rehabilitation and experimental therapies in addition to acute management trials. The list may serve as an archive and reference for further studies in this field.
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http://dx.doi.org/10.1080/10790268.2019.1576426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006647PMC
January 2020

Risk factors and clinical impact of perioperative neurological deficits following thoracolumbar arthrodesis.

Interdiscip Neurosurg 2018 Dec 13;14:18-23. Epub 2018 Apr 13.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Objectives: The rates of arthrodesis performed in the United States and globally have increased tremendously in the last 10-15 years. Amongst the most devastating complications are neurological deficits including spinal cord injury, nerve root irritation, and cauda equine syndrome. The primary purpose of this study is to understand the risk factors for perioperative neurological deficits in patients undergoing thoracolumbar fusion.

Patients And Methods: Data from the Nationwide Inpatient Sample between the years of 1999-2011 was analyzed. Patients were between the ages of 18 and 80 who had thoracolumbar fusion. Excluded were patients who underwent the procedure as a result of trauma or a malignancy. A list of covariates, including demographic variables, preoperative and postoperative variables that are known to increase the risk of perioperative neurological deficits were compiled. Statistical analysis utilized univariate and multivariate logistic regression for comparisons between these covariates and the proposed outcomes.

Results: The analysis of 37,899 patients yielded an overall rate of perioperative neurological deficits and mortality of 1.20% and 0.27%, respectively. Risk factors for perioperative neurological deficits included increasing age (OR 1.023 95% CI 1.018-1.029), Van Walraven 5-14 (OR 1.535 95% CI 1.054-2.235), and preoperative paralysis (OR 2.551 95% CI 1.674-3.886). Furthermore, the data showed that being 65 years old or older doubled the risk for perioperative deficit (OR 1.655, CI 1.248-2.194, p < 0.001).

Conclusions: This population based study found that increasing age, higher comorbid burden, and preoperative paralysis increased the risk of perioperative neurological deficits while female gender and hypertension were found to be protective.
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http://dx.doi.org/10.1016/j.inat.2018.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7377338PMC
December 2018

Cost-Effectiveness of a Radio Frequency Hemostatic Sealer (RFHS) in Adult Spinal Deformity Surgery.

World Neurosurg 2019 Feb 1;122:171-175. Epub 2018 Nov 1.

Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: Patients undergoing posterior spinal fusion surgery can lose a substantial amount of blood. This can prolong operative time and require transfusion of allogeneic blood components, which increases the risk of infection and can be the harbinger of serious complications. Does a saline-irrigated bipolar radiofrequency hemostatic sealer (RFHS) help reduce transfusion requirements?

Methods: In an observational cohort study, we compared transfusion requirements in 30 patients undergoing surgery for adult spinal deformity using the RFHS with that of a historical control group of 30 patients in which traditional hemostasis was obtained with bipolar electrocautery and matched them for blood loss-related variables. Total expense to the hospital for the RFHS, laboratory expenses, and blood transfusions was used for cost calculations. The incremental cost-effectiveness ratio was calculated using the number of blood transfusions avoided as the effectiveness payoff.

Results: Using a multivariable linear regression model, we found that only estimated blood loss (EBL) was an independent significant predictor of transfusion requirement in both groups. We evaluated the variables of age, EBL, time duration of surgery, preoperative hemoglobin, hemoglobin nadir during surgery, body mass index, length of stay, and number of levels operated on. Mean EBL was greater in the control group (2201 vs. 1416 mL, P = 0.0099). The number of transfusions also was greater in the control group (14.5 vs. 6.5, P = 0.0008). In the cost-effectiveness analysis, we found that the RFHS cost $108 more (compared with not using the RFHS) to avoid 1 unit of blood transfusion.

Conclusions: The cost-effectiveness analysis revealed that if we are willing to pay $108 to avoid 1 unit of blood transfusion, the use of the RFHS is a reasonable choice to use in open surgery for adult spinal deformity.
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http://dx.doi.org/10.1016/j.wneu.2018.10.131DOI Listing
February 2019

Epidural cerebrospinal fluid collection following lumbar puncture in an adult patient: A case report and literature review.

Surg Neurol Int 2018 22;9:169. Epub 2018 Aug 22.

University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

Background: Cerebrospinal fluid (CSF) leakage into the epidural space following lumbar puncture (LP) has been documented in pediatric patients, but there have been no reported cases in adults.

Case Description: We report an epidural CSF leak in an adult who presented with back pain, positional headache, urinary retention, and constipation following an LP performed as a part of a research study. The patient's magnetic resonance (MR) scan showed an extensive epidural CSF collection. Following placement in a recumbent position for 72 h, the collection fully resolved along with his neurological complaints.

Conclusion: Symptomatic epidural CSF collections rarely occur in adults following LPs. Nevertheless, the management remains the same as for pediatric patients; bed rest for 72 h results typically in full resolution of symptoms/signs and regression of the collection on MR studies.
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http://dx.doi.org/10.4103/sni.sni_476_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6122281PMC
August 2018

Lateral lumbar interbody fusion in the elderly: a 10-year experience.

J Neurosurg Spine 2018 Nov;29(5):525-529

OBJECTIVEElderly patients, often presenting with multiple medical comorbidities, are touted to be at an increased risk of peri- and postoperative complications following spine surgery. Various minimally invasive surgical techniques have been developed and employed to treat an array of spinal conditions while minimizing complications. Lateral lumbar interbody fusion (LLIF) is one such approach. The authors describe clinical outcomes in patients over the age of 70 years following stand-alone LLIF.METHODSA retrospective query of a prospectively maintained database was performed for patients over the age of 70 years who underwent stand-alone LLIF. Patients with posterior segmental fixation and/or fusion were excluded. The preoperative and postoperative values for the Oswestry Disability Index (ODI) were analyzed to compare outcomes after intervention. Femoral neck t-scores were acquired from bone density scans and correlated with the incidence of graft subsidence.RESULTSAmong the study cohort of 55 patients, the median age at the time of surgery was 74 years (range 70-87 years). Seventeen patients had at least 3 medical comorbidities at surgery. Twenty-three patients underwent a 1-level, 14 a 2-level, and 18 patients a 3-level or greater stand-alone lateral fusion. The median estimated blood loss was 25 ml (range 5-280 ml). No statistically significant relationship was detected between volume of blood loss and the number of operative levels. The median length of hospital stay was 2 days (range 1-4 days). No statistically significant relationship was observed between the length of hospital stay and age at the time of surgery. There was one intraoperative death secondary to cardiac arrest, with a mortality rate of 1.8%. One patient developed a transient femoral nerve injury. Five patients with symptomatic graft subsidence subsequently underwent posterior instrumentation. A lower femoral neck t-score < -1.0 correlated with a higher incidence of graft subsidence (p = 0.006). The mean ODI score 1 year postoperatively of 31.1 was significantly (p = 0.003) less than the mean preoperative ODI score of 46.2.CONCLUSIONSStand-alone LLIF can be safely and effectively performed in the elderly population. Careful evaluation of preoperative bone density parameters should be employed to minimize risk of subsidence and need for additional surgery. Despite an association with increased comorbidities, age alone should not be a deterrent when considering stand-alone LLIF in the elderly population.
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http://dx.doi.org/10.3171/2018.3.SPINE171147DOI Listing
November 2018

Robotic Stereotactic Assistance (ROSA) Utilization for Minimally Invasive Placement of Intraparenchymal Hematoma and Intraventricular Catheters.

World Neurosurg 2017 Dec 14;108:996.e7-996.e10. Epub 2017 Sep 14.

University of Pittsburgh Medical Center, Department of Neurological Surgery, Pittsburgh, Pennsylvania, USA. Electronic address:

Background: In patients with supratentorial spontaneous intracerebral hemorrhage, intrahematomal catheter placement may allow for intraclot thrombolysis and drainage. Robotic assistance may be used for the stereotactic placement of catheters.

Case Description: A 76-year-old male presented with altered mental status and left-sided weakness. Noncontrast computed tomography of the head showed a right ganglionic intraparenchymal hemorrhage with resultant entrapment of the temporal horn. Using Robotic Stereotactic Assistance, intrahematomal and intraventricular catheters were placed. The temporal horn was immediately decompressed, and the hematoma almost completely resolved with scheduled administration of intrathecal alteplase in the ensuing 48 hours postoperatively.

Conclusion: Frameless image-guided placement of intraparenchymal hematoma catheter using Robotic Stereotactic Assistance is safe and efficient.
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http://dx.doi.org/10.1016/j.wneu.2017.09.027DOI Listing
December 2017

Top 50 most cited articles on primary tumors of the spine.

J Clin Neurosci 2017 Aug 24;42:19-27. Epub 2017 Mar 24.

University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. Electronic address:

Citation analysis was performed in order to identify the top 50 most cited articles pertaining to the field of primary spinal tumors. This collection of articles highlights important trends in the neurosurgical literature. We searched the Thomson Reuters Web of Knowledge in order to identify articles pertaining to primary tumors of the spine. Impertinent articles were removed. The top 50 most cited articles were identified. Thereafter, article characteristics were determined including article type, article topic, level of evidence, and citation rate. The selected articles were published between 1951 and 2008. The most productive year was 1997 with 6 publications. The top 50 articles were published in twenty-two different journals, most commonly in Neurosurgery (12), Journal of Neurosurgery (8), and Spine (6). The most frequently cited article was by Tomita et al. written in 1997 which described total en bloc spondylectomy as a novel surgical technique in management of primary tumors of the vertebral column. We identified the 50 most-cited articles in the field of primary spinal tumors. This collection of articles serves as a reference for recognizing impactful studies in the field.
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http://dx.doi.org/10.1016/j.jocn.2017.02.019DOI Listing
August 2017

Top 50 most-cited articles on craniovertebral junction surgery.

J Craniovertebr Junction Spine 2017 Jan-Mar;8(1):22-32

Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.

Background: Craniovertebral junction is a complex anatomical location posing unique challenges to the surgical management of its pathologies. We aimed to identify the fifty most-cited articles that are dedicated to this field.

Methods: A keyword search using the Thomson Reuters Web of Knowledge was conducted to identify articles relevant to the field of craniovertebral junction surgery. The articles were reviewed based on title, abstract, and methods, if necessary, and then ranked based on the total number of citations to identify the fifty most-cited articles. Characteristics of the articles were determined and analyzed.

Results: The earliest top-cited article was published in 1948. When stratified by decade, 1990s was the most productive with 16 articles. The most-cited article was by Anderson and Dalonzo on a classification of odontoid fractures. By citation rate, the most-cited article was by Herms and Melcher who described Goel's technique of atlantoaxial fixation using C1 lateral mass screws and C2 pedicle screws with rod fixation. Atlantoaxial fixation was the most common topic. The United States, Barrow Neurological Institute, and VH Sonntag were the most represented country, institute, and author, respectively. The significant majority of articles were designed as case series providing level IV evidence.

Conclusion: Using citation analysis, we have provided a list of the most-cited articles representing important contributions of various authors from many institutions across the world to the field of craniovertebral junction surgery.
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http://dx.doi.org/10.4103/0974-8237.199883DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5324355PMC
March 2017

Management of Iatrogenic Direct Carotid Cavernous Fistula Occurring During Endovascular Treatment of Stroke.

World Neurosurg 2017 Apr 7;100:710.e15-710.e20. Epub 2017 Feb 7.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Traumatic carotid cavernous fistula may occur as a complication of endovascular treatment of acute stroke. We report 3 cases of such lesions. All patients were initially managed conservatively. Two patients have remained asymptomatic. One patient became symptomatic with right eye proptosis, chemosis, and right lateral gaze diplopia 3 weeks post thrombectomy. He underwent endovascular embolization via transfemoral transvenous approach via the inferior ophthalmic vein.
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http://dx.doi.org/10.1016/j.wneu.2017.01.112DOI Listing
April 2017

Risk associated with perioperative red blood cell transfusion in cranial surgery.

Neurosurg Rev 2017 Oct 3;40(4):633-642. Epub 2017 Feb 3.

The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, and Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.

We assessed the impact of intra- and postoperative RBC transfusion on postoperative morbidity and mortality in cranial surgery. A total of 8924 adult patients who underwent cranial surgery were identified in the 2006-2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing a biopsy, radiosurgery, or outpatient surgery were excluded. Propensity scores were calculated according to demographic variables, comorbidities, and preoperative laboratory values. Patients who had received RBC transfusion were matched to those who did not, by propensity score, preoperative hematocrit level, and by length of surgery, as an indirect measure of potential intraoperative blood loss. Logistic regression was used to predict adverse postoperative outcomes. A total of 625 (7%) patients were transfused with one or more units of packed RBCs. Upon matching, preoperative hematocrit, length of surgery, and emergency status were no longer different between transfused and non-transfused patients. RBC transfusion was associated with prolonged length of hospitalization (OR 1.6, 95% CI 1.2-2.2), postoperative complications (OR 2.8, 95% CI 2.0-3.8), 30-day return to operation room (OR 2.0, 95% CI 1.3-3.2), and 30-day mortality (OR 4.3, 95% CI 2.4-7.6). RBC transfusion is associated with substantive postoperative morbidity and mortality in patients undergoing both elective and emergency cranial surgery. These results suggest judicious use of transfusion in cranial surgery, consideration of alternative means of blood conservation, or pre-operative restorative strategies in patients undergoing elective surgery, when possible.
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http://dx.doi.org/10.1007/s10143-017-0819-yDOI Listing
October 2017

The 100 most cited articles in metastatic spine disease.

Neurosurg Focus 2016 Aug;41(2):E10

Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

OBJECTIVE Despite the growing neurosurgical literature, a subset of pioneering studies have significantly impacted the field of metastatic spine disease. The purpose of this study was to identify and analyze the 100 most frequently cited articles in the field. METHODS A keyword search using the Thomson Reuters Web of Science was conducted to identify articles relevant to the field of metastatic spine disease. The results were filtered based on title and abstract analysis to identify the 100 most cited articles. Statistical analysis was used to characterize journal frequency, past and current citations, citation distribution over time, and author frequency. RESULTS The total number of citations for the final 100 articles ranged from 74 to 1169. Articles selected for the final list were published between 1940 and 2009. The years in which the greatest numbers of top-100 studies were published were 1990 and 2005, and the greatest number of citations occurred in 2012. The majority of articles were published in the journals Spine (15), Cancer (11), and the Journal of Neurosurgery (9). Forty-four individuals were listed as authors on 2 articles, 9 were listed as authors on 3 articles, and 2 were listed as authors on 4 articles in the top 100 list. The most cited article was the work by Batson (1169 citations) that was published in 1940 and described the role of the vertebral veins in the spread of metastases. The second most cited article was Patchell's 2005 study (594 citations) discussing decompressive resection of spinal cord metastases. The third most cited article was the 1978 study by Gilbert that evaluated treatment of epidural spinal cord compression due to metastatic tumor (560 citations). CONCLUSIONS The field of metastatic spine disease has witnessed numerous milestones and so it is increasingly important to recognize studies that have influenced the field. In this bibliographic study the authors identified and analyzed the most influential articles in the field of metastatic spine disease.
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http://dx.doi.org/10.3171/2016.5.FOCUS16158DOI Listing
August 2016

Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor.

J Clin Neurosci 2015 Sep 12;22(9):1413-9. Epub 2015 Jun 12.

The Rose Ella Burkhardt Brain Tumor and Neuro-Oncology Center, Department of Neurosurgery, The Neurological Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.

We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.
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http://dx.doi.org/10.1016/j.jocn.2015.03.009DOI Listing
September 2015

Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms.

J Neurosurg 2015 Jul 10;123(1):91-100. Epub 2015 Apr 10.

Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio.

Object: Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms.

Methods: The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hours postoperatively. The authors separately compared surgical outcome between patients with (n = 198) versus without (n = 470) anemia, and those who underwent (n = 78) versus those who did not receive (n = 521) a transfusion, using a 1:1 match on propensity score.

Results: In the matched cohorts, all observed covariates were comparable between anemic (n = 147) versus nonanemic (n = 147) and between transfused (n = 67) versus nontransfused patients (n = 67). Anemia was independently associated with prolonged hospital length of stay (LOS; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.5), perioperative complications (OR 1.9, 95% CI 1.1-3.1), and return to the operating room (OR 2.1, 95% CI 1.1-4.5). Transfusion was also independently associated with perioperative complications (OR 2.4, 95% CI 1.1-5.3).

Conclusions: Preoperative anemia and transfusion are each independent risk factors for perioperative complications in patients undergoing surgery for cerebral aneurysms. Perioperative anemia is also associated with prolonged hospital LOS and 30-day return to the operating room.
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http://dx.doi.org/10.3171/2014.10.JNS14551DOI Listing
July 2015

Surgeon specialty and outcomes after elective spine surgery.

Spine (Phila Pa 1976) 2014 Sep;39(19):1605-13

*Case Western Reserve University School of Medicine, Cleveland, OH †Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH ‡Departments of Pulmonary, Critical Care, and Sleep Medicine, University Hospitals, Cleveland, OH §Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH ¶The Department of Neurosurgery ‖The Spine Center, and **The Rose Ella Burkhardt Brain Tumor and Neurooncology Center, The Neurological Institute, Cleveland Clinic, Cleveland, OH; and ††Department of Neurosurgery, Geisinger Health System, Danville, PA.

Study Design: Retrospective cohort analysis of prospectively collected clinical data.

Objective: To compare outcomes of elective spine fusion and laminectomy when performed by neurological and orthopedic surgeons.

Summary Of Background Data: The relationship between primary specialty training and outcome of spinal surgery is unknown.

Methods: We analyzed the 2006 to 2012 American College of Surgeons National Surgical Quality Improvement Project database of 50,361 patients, 33,235 (66%) of which were operated on by a neurosurgeon. We eliminated all differences in preoperative and intraoperative risk factors between surgical specialties by matching 17,126 patients who underwent orthopedic surgery (OS) to 17,126 patients who underwent neurosurgery (NS) on propensity scores. Regular and conditional logistic regressions were used to predict adverse postoperative outcomes in the full sample and matched sample, respectively. The effect of perioperative transfusion on outcomes was further assessed in the matched sample.

Results: Diagnosis and procedure were the only factors that were found to be significantly different between surgical subspecialties in the full sample. We found that compared with patients who underwent NS, patients who underwent OS were more than twice as likely to experience prolonged length of stay (LOS) (odds ratio: 2.6, 95% confidence interval: 2.4-2.8), and significantly more likely to receive a transfusion perioperatively, have complications, and to require discharge with continued care. After matching, patients who underwent OS continued to have slightly higher odds for prolonged LOS, and twice the odds for receiving perioperative transfusion compared with patients who underwent NS. Taking into account perioperative transfusion did not eliminate the difference in LOS between patients who underwent OS and those who underwent NS.

Conclusion: Patients operated on by OS have twice the odds for undergoing perioperative transfusion and slightly increased odds for prolonged LOS. Other differences between surgical specialties in 30-day postoperative outcomes were minimal. Analysis of a large, multi-institutional sample of prospectively collected clinical data suggests that surgeon specialty has limited influence on short-term outcomes after elective spine surgery.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000000489DOI Listing
September 2014
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