Publications by authors named "Paul Marcotte"

22 Publications

  • Page 1 of 1

Predicting patient outcomes after far lateral lumbar discectomy.

Clin Neurol Neurosurg 2021 Apr 3;203:106583. Epub 2021 Mar 3.

Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; McKenna EpiLog Fellowship in Population Health, at the University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

Introduction: The LACE+ (Length of Stay, Acuity of Admission, Charlson Comorbidity Index (CCI) Score, Emergency Department (ED) visits within the previous 6 months) index has never been tested in a purely spine surgery population. This study assesses the ability of LACE + to predict adverse patient outcomes following discectomy for far lateral disc herniation (FLDH).

Patients And Methods: Data were obtained for patients (n = 144) who underwent far lateral lumbar discectomy at a single, multi-hospital academic medical center (2013-2020). LACE + scores were calculated for all patients with complete information (n = 100). The influence of confounding variables was assessed and controlled with stepwise regression. Logistic regression was used to test the ability of LACE + to predict risk of unplanned hospital readmission, ED visits, outpatient office visits, and reoperation after surgery.

Results: Mean age of the population was 61.72 ± 11.55 years, 69 (47.9 %) were female, and 126 (87.5 %) were non-Hispanic white. Patients underwent either open (n = 92) or endoscopic (n = 52) surgery. Each point increase in LACE + score significantly predicted, in the 30-day (30D) and 30-90-day (30-90D) post-discharge window, higher risk of readmission (p = 0.005, p = 0.009; respectively) and ED visits (p = 0.045). Increasing LACE + also predicted, in the 30D and 90-day (90D) post-discharge window, risk of reoperation (p = 0.022, p = 0.016; respectively), and repeat neurosurgical intervention (p = 0.026, p = 0.026; respectively). Increasing LACE + score also predicted risk of reoperation (p = 0.011) within 30 days of initial surgery.

Conclusions: LACE + may be suitable for characterizing risk of adverse perioperative events for patients undergoing far lateral discectomy.
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http://dx.doi.org/10.1016/j.clineuro.2021.106583DOI Listing
April 2021

Telemedicine in the Era of Coronavirus Disease 2019 (COVID-19): A Neurosurgical Perspective.

World Neurosurg 2020 07 16;139:549-557. Epub 2020 May 16.

Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Despite the substantial growth of telemedicine and the evidence of its advantages, the use of telemedicine in neurosurgery has been limited. Barriers have included medicolegal issues surrounding provider reimbursement, interstate licensure, and malpractice liability as well as technological challenges. Recently, the coronavirus disease 2019 (COVID-19) pandemic has limited typical evaluation of patients with neurologic issues and resulted in a surge in demand for virtual medical visits. Meanwhile, federal and state governments took action to facilitate the rapid implementation of telehealth programs, placing a temporary lift on medicolegal barriers that had previously limited its expansion. This created a unique opportunity for widespread telehealth use to meet the surge in demand for remote medical care. After initial hurdles and challenges, our experience with telemedicine in neurosurgery at Penn Medicine has been overall positive from both the provider and the patients' perspective. One of the unique challenges we face is guiding patients to appropriately set up devices in a way that enables an effective neuroexamination. However, we argue that an accurate and comprehensive neurologic examination can be conducted through a telemedicine platform, despite minor weaknesses inherent to absence of physical presence. In addition, certain neurosurgical visits such as postoperative checks, vascular pathology, and brain tumors inherently lend themselves to easier evaluation through telehealth visits. In the era of COVID-19 and beyond, telemedicine remains a promising and effective approach to continue neurologic patient care.
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http://dx.doi.org/10.1016/j.wneu.2020.05.066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7229725PMC
July 2020

Association of spinal instability due to metastatic disease with increased mortality and a proposed clinical pathway for treatment.

J Neurosurg Spine 2020 Feb 14:1-8. Epub 2020 Feb 14.

Departments of2Neurosurgery and.

Objective: Multidisciplinary treatment including medical oncology, radiation oncology, and surgical consultation is necessary to provide comprehensive therapy for patients with spinal metastases. The goal of this study was to review the use of radiation therapy and/or surgical intervention and their impact on patient outcomes.

Methods: In this retrospective series, the authors identified at their institution those patients with spinal metastases who had received radiation therapy alone or had undergone surgery with or without radiation therapy within a 6-year period. Data on patient age, chemotherapy, surgical procedure, radiation therapy, Karnofsky Performance Status (KPS), primary tumor pathology, Spinal Instability Neoplastic Score (SINS), and survival after treatment were collected from the patient electronic medical records. N - 1 chi-square testing was used for comparisons of proportions. The Student t-test was used for comparisons of means. A p value < 0.05 was considered statistically significant. A survival analysis was completed using a multivariate Cox proportional hazards model.

Results: Two hundred thirty patients with spinal metastases were identified, 109 of whom had undergone surgery with or without radiation therapy. Among the 104 patients for whom the surgical details were reviewed, 34 (33%) had a history of preoperative radiation to the surgical site but ultimately required surgical intervention. In this surgical group, a significantly increased frequency of death within 30 days was noted for the SINS unstable patients (23.5%) as compared to that for the SINS stable patients (2.3%; p < 0.001). The SINS was a significant predictor of time to death among surgical patients (HR 1.11, p = 0.037). Preoperative KPS was not independently associated with decreased survival (p > 0.5) on univariate analysis. One hundred twenty-six patients met the criteria for inclusion in the radiation-only analysis. Ninety-eight of these patients (78%) met the criteria for potential instability (PI) at the time of treatment, according to the SINS system. Five patients (5%) with PI in the radiation therapy group had a documented neurosurgical or orthopedic surgery consultation prior to radiation therapy.

Conclusions: At the authors' institution, patients with gross mechanical instability per the SINS system had an increased rate of 30-day postoperative mortality, which remained significant when controlling for other factors. Surgical consultation for metastatic spine patients receiving radiation oncology consultation with PI is low. The authors describe an institutional pathway to encourage multidisciplinary treatment from the initial encounter in the emergency department to expedite surgical evaluation and collaboration.
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http://dx.doi.org/10.3171/2019.11.SPINE19775DOI Listing
February 2020

Assessing variability in surgical decision making among attending neurosurgeons at an academic center.

J Neurosurg 2019 May 31;132(6):1970-1976. Epub 2019 May 31.

1Department of Neurosurgery and.

Objective: Although it is known that intersurgeon variability in offering elective surgery can have major consequences for patient morbidity and healthcare spending, data addressing variability within neurosurgery are scarce. The authors performed a prospective peer review study of randomly selected neurosurgery cases in order to assess the extent of consensus regarding the decision to offer elective surgery among attending neurosurgeons across one large academic institution.

Methods: All consecutive patients who had undergone standard inpatient surgical interventions of 1 of 4 types (craniotomy for tumor [CFT], nonacute redo CFT, first-time spine surgery with/without instrumentation, and nonacute redo spine surgery with/without instrumentation) during the period 2015-2017 were retrospectively enrolled (n = 9156 patient surgeries, n = 80 randomly selected individual cases, n = 20 index cases of each type randomly selected for review). The selected cases were scored by attending neurosurgeons using a need for surgery (NFS) score based on clinical data (patient demographics, preoperative notes, radiology reports, and operative notes; n = 616 independent case reviews). Attending neurosurgeon reviewers were blinded as to performing provider and surgical outcome. Aggregate NFS scores across various categories were measured. The authors employed a repeated-measures mixed ANOVA model with autoregressive variance structure to compute omnibus statistical tests across the various surgery types. Interrater reliability (IRR) was measured using Cohen's kappa based on binary NFS scores.

Results: Overall, the authors found that most of the neurosurgical procedures studied were rated as "indicated" by blinded attending neurosurgeons (mean NFS = 88.3, all p values < 0.001) with greater agreement among neurosurgeon raters than expected by chance (IRR = 81.78%, p = 0.016). Redo surgery had lower NFS scores and IRR scores than first-time surgery, both for craniotomy and spine surgery (ANOVA, all p values < 0.01). Spine surgeries with fusion had lower NFS scores than spine surgeries without fusion procedures (p < 0.01).

Conclusions: There was general agreement among neurosurgeons in terms of indication for surgery; however, revision surgery of all types and spine surgery with fusion procedures had the lowest amount of decision consensus. These results should guide efforts aimed at reducing unnecessary variability in surgical practice with the goal of effective allocation of healthcare resources to advance the value paradigm in neurosurgery.
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http://dx.doi.org/10.3171/2019.2.JNS182658DOI Listing
May 2019

Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution.

J Neurosurg Spine 2019 Jan 25:1-9. Epub 2019 Jan 25.

1Department of Neurosurgery.

OBJECTIVEEnhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient's surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.METHODSThe authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September-December 2016) underwent traditional surgical care. Patients in the intervention group (April-June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.RESULTSA total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).CONCLUSIONSImplementation of this novel ERAS pathway safely reduces patients' postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.
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http://dx.doi.org/10.3171/2018.9.SPINE18681DOI Listing
January 2019

Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation.

J Neurosurg Spine 2018 11;30(1):78-82

1Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; and.

OBJECTIVEHealthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors' objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.METHODSThe authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient's chart and the hospital's billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score-matching analysis to compare the two cohorts (n = 180).RESULTSDirect hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score-matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).CONCLUSIONSBoth SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.
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http://dx.doi.org/10.3171/2018.7.SPINE18460DOI Listing
November 2018

A Prospective Detailed Time Analysis Study of 18 Patients Undergoing Elective Single-Level Open Lumbar Microdiscectomy Spinal Surgery Compared with Centers for Medicare and Medicaid Services Reimbursement Guidelines.

World Neurosurg 2018 Nov 10;119:e666-e670. Epub 2018 Aug 10.

Department of Neurosurgery, University of Pennsylvania, Philadephia, Pennsylvania, USA.

Background: Single-level open lumbar microdiscectomy surgery is one of the most straightforward and effective spinal surgeries performed by spinal surgeons today to treat disk herniation. Although a common operation, little in the literature is reported on the exact overall time, cost, and effort associated with the performance of this surgery. The consistency of this operation across institutions and disciplines makes it a good starting point to accurately track the total time and effort of all phases of the surgical intervention.

Methods: Eighteen patients undergoing elective single-level open lumbar microdiscectomy surgery were prospectively enrolled in this study. The time spent interacting with each patient by every member of the surgical team was tracked and recorded along will every phone call and e-mail. All perioperative times associated with the surgery were tracked and analyzed. Each patient was followed from their first interaction through surgery and for the first 3 months postoperatively.

Results: The advanced practice providers spent the most time with the patient both pre- and postoperatively followed by the surgeon and resident. A total of 2.98 hours was spent with the patient preoperatively in clinic and 1.69 hours postoperatively. The total time commitment of an institution treating this condition was 12.56 hours.

Conclusions: Comparing our results with the Centers for Medicare and Medicaid Services data, a significant discrepancy and underestimation was observed. As such, we hope our results enable health care providers to more accurately allocate resources for the provision of high-quality medical care to patients with this increasingly common condition.
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http://dx.doi.org/10.1016/j.wneu.2018.07.239DOI Listing
November 2018

Pre-optimization of spinal surgery patients: Development of a neurosurgical enhanced recovery after surgery (ERAS) protocol.

Clin Neurol Neurosurg 2018 01 8;164:142-153. Epub 2017 Dec 8.

Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States.

Objective: Despite surgical, technological, medical, and anesthetic improvements, patient outcomes following elective neurosurgical procedures can be associated with high morbidity. Enhanced recovery after surgery (ERAS) protocols are multimodal care pathways designed to optimize patient outcomes by addressing pre-, peri-, and post-operative factors. Despite significant data suggesting improved patient outcomes with the adoption of these pathways, development and implementation has been limited in the neurosurgical population.

Methods/results: This study protocol was designed to establish the feasibility of a randomized controlled trial to assess the efficacy of implementation of an ERAS protocol on the improvement of clinical and patient reported outcomes and patient satisfaction scores in an elective inpatient spine surgery population. Neurosurgical patients undergoing spinal surgery will be recruited and randomly allocated to one of two treatment arms: ERAS protocol (experimental group) or hospital standard (control group). The experimental group will undergo interventions at the pre-, peri-, and post-operative time points, which are exclusive to this group as compared to the hospital standard group.

Conclusions: The present proposal aims to provide supporting data for the application of these specific ERAS components in the spine surgery population and provide rationale/justification of this type of care pathway. This study will help inform the design of a future multi-institutional, randomized controlled trial.

Results: of this study will guide further efforts to limit post-operative morbidity in patients undergoing elective spinal surgery and to highlight the impact of ERAS care pathways in improving patient reported outcomes and satisfaction.
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http://dx.doi.org/10.1016/j.clineuro.2017.12.003DOI Listing
January 2018

Posterior Cervical Laminectomy Results in Better Radiographic Decompression of Spinal Cord Compared with Anterior Cervical Discectomy and Fusion.

World Neurosurg 2018 Feb 11;110:e362-e366. Epub 2017 Nov 11.

Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Cervical spondylitic myelopathy is a degenerative condition resulting from chronic spinal cord compression and a leading cause of nontraumatic spinal cord dysfunction. The chief surgical goal in the management of cervical spondylitic myelopathy is adequate spinal cord decompression with or without fusion to slow or prevent further neurologic decline. We conducted a radiographic analysis of canal parameters preoperatively and postoperatively for patients undergoing either anterior or posterior cervical decompression.

Methods: Preoperative and postoperative radiographic analysis was performed using midsagittal and axial magnetic resonance imaging at the level of the disc space for 37 patients who underwent anterior or posterior cervical decompression. Statistical comparisons between anterior and posterior groups were performed using independent t test and Mann-Whitney U test where appropriate.

Results: Both postoperative anteroposterior canal diameter and posterior cerebrospinal fluid (CSF) space were greater in patients undergoing posterior decompression (P = 0.011 and P < 0.001, respectively), although postoperative anterior CSF space was comparable between both groups. Both anterior and posterior approaches to decompression resulted in a statistically significant improvement in anteroposterior diameter, anterior CSF space, and posterior CSF space (P < 0.001). Posterior decompression yielded significantly greater change in anteroposterior diameter and posterior CSF space compared with the anterior approach (P < 0.001).

Conclusions: In this quantitative radiographic study, we found that although both posterior cervical laminectomy and anterior cervical discectomy yielded significant decompression, laminectomy yielded a greater degree of decompression of the posterior CSF space.
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http://dx.doi.org/10.1016/j.wneu.2017.11.017DOI Listing
February 2018

Efficiency of spinal anesthesia versus general anesthesia for lumbar spinal surgery: a retrospective analysis of 544 patients.

Local Reg Anesth 2017 10;10:91-98. Epub 2017 Oct 10.

Department of Neurosurgery.

Background: Previous studies have shown varying results in selected outcomes when directly comparing spinal anesthesia to general in lumbar surgery. Some studies have shown reduced surgical time, postoperative pain, time in the postanesthesia care unit (PACU), incidence of urinary retention, postoperative nausea, and more favorable cost-effectiveness with spinal anesthesia. Despite these results, the current literature has also shown contradictory results in between-group comparisons.

Materials And Methods: A retrospective analysis was performed by querying the electronic medical record database for surgeries performed by a single surgeon between 2007 and 2011 using procedural codes 63030 for diskectomy and 63047 for laminectomy: 544 lumbar laminectomy and diskectomy surgeries were identified, with 183 undergoing general anesthesia and 361 undergoing spinal anesthesia (SA). Linear and multivariate regression analyses were performed to identify differences in blood loss, operative time, time from entering the operating room (OR) until incision, time from bandage placement to exiting the OR, total anesthesia time, PACU time, and total hospital stay. Secondary outcomes of interest included incidence of postoperative spinal hematoma and death, incidence of paraparesis, plegia, post-dural puncture headache, and paresthesia, among the SA patients.

Results: SA was associated with significantly lower operative time, blood loss, total anesthesia time, time from entering the OR until incision, time from bandage placement until exiting the OR, and total duration of hospital stay, but a longer stay in the PACU. The SA group experienced one spinal hematoma, which was evacuated without any long-term neurological deficits, and neither group experienced a death. The SA group had no episodes of paraparesis or plegia, post-dural puncture headaches, or episodes of persistent postoperative paresthesia or weakness.

Conclusion: SA is effective for use in patients undergoing elective lumbar laminectomy and/or diskectomy spinal surgery, and was shown to be the more expedient anesthetic choice in the perioperative setting.
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http://dx.doi.org/10.2147/LRA.S141233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5644537PMC
October 2017

19-Year-Old Male with Headaches and a Possible Seizure.

Brain Pathol 2017 07;27(4):557-558

Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

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http://dx.doi.org/10.1111/bpa.12529DOI Listing
July 2017

Civilian gunshot wounds to the atlantoaxial spine: a report of 10 cases treated using a multidisciplinary approach.

J Neurosurg Spine 2013 Dec 20;19(6):759-66. Epub 2013 Sep 20.

Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania;

Object: Gunshot wounds to the atlantoaxial spine are uncommon injuries and rarely require treatment, as a bullet traversing this segment often results in a fatal injury. Additionally, these injuries are typically biomechanically stable. The authors report a series of 10 patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex. Their care is discussed and conclusions are drawn from these cases to identify the optimal treatment for these injuries.

Methods: A retrospective review was conducted of patients presenting to the emergency rooms of 3 institutions with gunshot wounds involving the atlantoaxial spine. Mechanism of injury and neurological status were obtained, as was the extent of the osteoligamentous, vascular, and neurological injuries. Nonoperative and operative treatment, complications, and clinical and radiographic outcome were recorded. The data were then analyzed to determine the neurological and biomechanical prognosis of these injuries, the utility of the various diagnostic modalities in the acute management of the injuries, and the nature and effectiveness of the nonoperative and operative treatment modalities.

Results: Ten patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex were identified. All but 2 patients sustained a vertebral artery injury. Each patient was evaluated using cervical radiographs, CT scans, and vascular imaging, 8 in the form of digital subtraction angiography and 2 with high-resolution CT angiography. Uncomplicated patients were treated conservatively using cervical collar immobilization, local wound care, and antibiotics. One patient was treated using a halo for instability and 1 underwent posterior fusion following a posterolateral decompression for delayed myelopathy. One patient underwent transoral resection of a bullet fragment. One patient underwent embolization for a symptomatic arteriovenous fistula and a second patient underwent a neck exploration and a jugular vein ligation. None of the patients received anticoagulation therapy. The mean follow-up duration was 13 months. All but 2 patients regained their previous functional status and all ultimately attained a mechanically stable spine.

Conclusions: These 10 patients represent a rare form of cervical spine penetrating injury. Unilateral gunshot wounds to the atlantoaxial complex are usually stable and the need for acute surgical intervention is rare. Unilateral vertebral artery injury is well tolerated and any information provided by angiography does not alter the acute management of the patient. Vascular complications from gunshot wounds can be managed effectively by endovascular techniques.
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http://dx.doi.org/10.3171/2013.8.SPINE12907DOI Listing
December 2013

Cost-effectiveness of confirmatory techniques for the placement of lumbar pedicle screws.

Neurosurg Focus 2012 Jul;33(1):E12

Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.

Object: There is considerable variation in the use of adjunctive technologies to confirm pedicle screw placement. Although there is literature to support the use of both neurophysiological monitoring and isocentric fluoroscopy to confirm pedicle screw positioning, there are no studies examining the cost-effectiveness of these technologies. This study compares the cost-effectiveness and efficacy of isocentric O-arm fluoroscopy, neurophysiological monitoring, and postoperative CT scanning after multilevel instrumented fusion for degenerative lumbar disease.

Methods: Retrospective data were collected from 4 spine surgeons who used 3 different strategies for monitoring of pedicle screw placement in multilevel lumbar degenerative disease. A decision analysis model was developed to analyze costs and outcomes of the 3 different monitoring strategies. A total of 448 surgeries performed between 2005 and 2010 were included, with 4 cases requiring repeat operation for malpositioned screws. A sample of 64 of these patients was chosen for structured interviews in which the EuroQol-5D questionnaire was used. Expected costs and quality-adjusted life years were calculated based on the incidence of repeat operation and its negative effect on quality of life and costs.

Results: The decision analysis model demonstrated that the O-arm monitoring strategy is significantly (p < 0.001) less costly than the strategy of postoperative CT scanning following intraoperative uniplanar fluoroscopy, which in turn is significantly (p < 0.001) less costly than neurophysiological monitoring. The differences in effectiveness of the different monitoring strategies are not significant (p = 0.92).

Conclusions: Use of the O-arm for confirming pedicle screw placement is the least costly and therefore most cost-effective strategy of the 3 techniques analyzed.
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http://dx.doi.org/10.3171/2012.2.FOCUS121DOI Listing
July 2012

A patient with thoracic intradural disc herniation.

J Clin Neurosci 2011 Dec 15;18(12):1730-2. Epub 2011 Oct 15.

Department of Neurosurgery, Hospital of The University of Pennsylvania, 3400 Spruce Street, 3rd Floor Silverstein, Philadelphia, PA 19104, USA.

Intradural disc herniation is a rare disease that occurs most commonly in the lumbar region, while fewer than 5% occur in the thoracic and cervical regions. We report a patient with thoracic intradural disc herniation at T12-L1 who presented with radiculopathy and motor weakness. The preoperative MRI did not demonstrate an intradural lesion, and it was identified intraoperatively by inspection and palpation of the thecal sac. The disc was removed, and the patient experienced good neurological recovery and remains pain free 1 year after surgery.
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http://dx.doi.org/10.1016/j.jocn.2011.04.021DOI Listing
December 2011

Esophageal stent-induced fistulization to an anterior cervical plate.

Gastrointest Endosc 2011 Jul;74(1):219-21

Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

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http://dx.doi.org/10.1016/j.gie.2011.01.009DOI Listing
July 2011

Cervical arthroplasty.

J Neurosurg Spine 2007 Sep;7(3):375-6; author reply 376

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http://dx.doi.org/10.3171/SPI-07/09/375DOI Listing
September 2007

Papilledema as a manifestation of a spinal subdural abscess.

J Neurol Sci 2007 Sep 13;260(1-2):288-92. Epub 2007 Jun 13.

Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA, United States.

Papilledema is an uncommon presentation of spinal cord processes. Spinal subdural abscess (SSA) is a rare site of post-operative infection. We report a patient who developed papilledema as the primary manifestation of a post-operative lumbar subdural abscess. A spinal abscess should be considered in the post-operative spinal surgery patient who develops papilledema in the setting of persistent back pain. The increased intracranial pressure associated with lumbar spinal cord abscess most likely results from a markedly elevated cerebrospinal fluid (CSF) protein or the disruption of CSF flow in the spinal cul-de-sac.
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http://dx.doi.org/10.1016/j.jns.2007.05.013DOI Listing
September 2007

Bleeding risk with ketorolac after lumbar microdiscectomy.

J Spinal Disord Tech 2007 Apr;20(2):123-6

Spine Surgery Service, Department of Orthopaedics, University of Pennsylvania Medical School, Philadelphia, PA 19104, USA.

There is a need to improve postoperative analgesia to support the trend to shorter hospitalization after minimally invasive spine surgeries. Ketorolac Tromethamine has proven efficacy in decreasing postoperative pain but there is concern with postoperative epidural bleeding after spine procedures. We prospectively assessed the incidence of bleeding complications after microdiscectomy in patients treated with a single 30 mg intraoperative dose of Ketorolac subsequent to wound closure. Group 1 consisted of 44 patients, 24 women and 20 men with mean age of 35.7 years (20 to 68 y) treated with Ketorolac. Group 2 consisted of 45 patients, 28 men and 17 women with mean age 46.8 years (32 to 74 y), who underwent discectomy without Ketorolac. Postoperative bleeding complications were monitored along with pain levels and time to discharge. We detected no significant postoperative changes in coagulation parameters or bleeding from the surgical site in either group. Both group 1 and 2 had averaged preoperative visual analog scale scores for leg pain of 8. Group 1 had an average postoperative visual analog scale score of 2.6 compared with 4 for group 2 two hours after surgery. Single dose intravenous Ketorolac provided beneficial analgesia without significant increase in risk of bleeding after microdiscectomy, enabling us to consistently perform microdiscectomy as an ambulatory procedure. Meticulous hemostasis should be accomplished before closure. Prolonged postoperative use is a promising alternative to narcotics.
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http://dx.doi.org/10.1097/01.bot.0000211163.51605.aeDOI Listing
April 2007

Recurring polysomatic hemangiomatosis: a new syndrome?

J Pediatr Hematol Oncol 2006 Jul;28(7):471-5

Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.

Systemic hemangiomatosis is extremely rare in adolescents and adults. The authors describe a 37-year-old man with a history of hepatic, splenic, cerebral, and multiple recurring osseous hemangiomas since age 14. After a 9-year period without disease progression, the patient presented with an acute bilateral lower extremity myelopathy. This was secondary to a T11 vertebral hemangioma that compressed the spinal cord. A 2-week course of radiation therapy failed to alleviate the patient's symptoms. Successful T11 vertebrectomy was then performed to decompress the spinal cord. The many organs and serially involved bones may represent a distinct variant of hemangiomatosis not previously described in the literature.
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http://dx.doi.org/10.1097/01.mph.0000212943.74737.2eDOI Listing
July 2006

Zero efficacy with cesium chloride self-treatment for brain cancer.

Mayo Clin Proc 2004 Dec;79(12):1588; author reply 1588-9

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http://dx.doi.org/10.4065/79.12.1588-aDOI Listing
December 2004

Spine surgery in morbidly obese patients.

J Neurosurg 2002 Jul;97(1 Suppl):20-4

Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, USA.

Object: The diagnosis, treatment, and postoperative care of morbidly obese patients undergoing spinal surgery require modifications for body habitus. With a growing percentage of the United States population becoming morbidly obese, the surgeon may need elective or emergency treatment plans that address the special needs of these patients. The authors retrospectively reviewed the diagnosis, treatment, and postoperative care of the severely obese patient undergoing spinal surgery.

Methods: To assess the associated results and complications of management that required modification for body habitus, 12 patients were included in the study (nine females); the mean age was 50 years and mean weight was 320 lb. Cases of cervical (two cases), thoracic (four cases), and lumbar surgeries (six cases) were included. The follow-up period ranged from 6 months to 2 years. Patients presented with myelopathy (five cases), radicular pain and weakness (four cases), radiculopathy (two cases), and cauda equina syndrome (one patient). Chronic progressive neurological deterioration secondary to spinal cord compression was demonstrated in nine patients and acute pain and/or weakness secondary to nerve root compression was observed in three patients.

Conclusions: The authors found that although morbidly obese patients may present late in the course of their symptoms and require modifications in the use of standard neuroimaging, operative facilities, and treatment plans, open mindedness and persistence can yield satisfactory results in most cases.
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http://dx.doi.org/10.3171/spi.2002.97.1.0020DOI Listing
July 2002