Publications by authors named "Piyush Kalakoti"

96 Publications

Associations of Baseline Frailty Status and Age With Outcomes in Patients Undergoing Vestibular Schwannoma Resection.

JAMA Otolaryngol Head Neck Surg 2021 07;147(7):608-614

Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque.

Importance: Although numerous studies have evaluated the influence of advanced age on surgical outcomes following vestibular schwannoma (VS) resection, few if any large-scale investigations have assessed the comparative prognostic effects of age and frailty. As the population continues to age, it is imperative to further evaluate treatment and management strategies for older patients.

Objective: To conduct a population-based evaluation of the independent associations of chronological age and frailty (physiological age) with outcomes following VS resection.

Design, Setting, And Participants: In this large-scale, multicenter, cross-sectional analysis, weighted discharge data from the National Inpatient Sample were searched to identify adult patients (≥18 years old) who underwent VS resection from 2002 through 2017 using International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision, Clinical Modification codes. Data collection and analysis took place September to December 2020.

Main Outcomes And Measures: Complex samples regression models and receiver operating characteristic curve analysis were used to evaluate the independent associations of frailty and age (along with demographic confounders) with complications and discharge disposition. Frailty was evaluated using the previously validated 11-point modified frailty index (mFI).

Results: Among the 27 313 patients identified for VS resection, the mean (SEM) age was 50.4 (0.2) years, 15 031 (55.0%) were women, and 4720 (21.0%) were of non-White race/ethnicity, as determined by the National Inpatient Sample data source. Of the included patients, 15 090 (55.2%) were considered robust (mFI score = 0), 8204 (30.0%) were prefrail (mFI score = 1), 3022 (11.1%) were frail (mFI score = 2), and 996 (3.6%) were severely frail (mFI score ≥3). On univariable analysis, increasing frailty was associated with development of postoperative hemorrhagic or ischemic stroke (odds ratio [OR], 2.44 [95% CI, 2.07-2.87]; area under the curve, 0.73), while increasing age was not. Following multivariable analysis, increasing frailty and non-White race/ethnicity were independently associated with both mortality (adjusted OR [aOR], 2.32 [95% CI, 1.70-3.17], and aOR, 3.05 [95% CI, 1.02-9.12], respectively) and extended hospital stays (aOR, 1.54 [95% CI, 1.41-1.67], and aOR, 1.71 [95% CI, 1.42-2.05], respectively), while increasing age was not. Increasing frailty (aOR, 0.61 [95% CI, 0.56-0.67]), age (aOR, 0.98 [95% CI, 0.97-0.99]), and non-White race/ethnicity (aOR, 0.62 [95% CI 0.51-0.75]) were all independently associated with routine discharge.

Conclusions And Relevance: In this cross-sectional study, findings suggest that frailty may be more accurate for predicting outcomes and guiding treatment decisions than advanced patient age alone following VS resection.
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http://dx.doi.org/10.1001/jamaoto.2021.0670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8085763PMC
July 2021

Biomarkers of Seizure Activity in Patients With Intracranial Metastases and Gliomas: A Wide Range Study of Correlated Regions of Interest.

Front Neurol 2020 29;11:444. Epub 2020 May 29.

Department of Neurosurgery, Robert Wood Johnson Medical School, New Brunswick, NJ, United States.

Studies quantifying cortical metrics in brain tumor patients who present with seizures are limited. The current investigation assesses morphometric/volumetric differences across a wide range of anatomical regions, including temporal and extra-temporal, in patients with gliomas and intracranial metastases (IMs) presenting with seizures that could serve as a biomarker in the identification of seizure expression and serve as a neuronal target for mitigation. In a retrospective design, the MR sequences of ninety-two tumor patients [55% gliomas; 45% IM] and 34 controls were subjected to sophisticated morphometric and volumetric assessments using BrainSuite and MATLAB modules. We examined 103 regions of interests (ROIs) across eight distinct cortical categories of interests (COI) [gray matter, white matter; total volume, CSF; cortical areas: inner, mid, pial; cortical thickness]. The primary endpoint was quantifying and identifying ROIs with significant differences in z-scores based upon the presence of seizures. Feature selection employing neighborhood component analysis (NCA) determined the ROI within each COI having the highest significance/weight in the differentiation of seizure vs. non-seizure patients harboring brain tumor. Overall, the mean age of the cohort was 58.0 ± 12.8 years, and 45% were women. The prevalence of seizures in tumor patients was 28%. Forty-two ROIs across the eight pre-defined COIs had significant differences in z-scores between tumor patients presenting with and without seizures. The NCA feature selection noted the volume of pars-orbitalis and right middle temporal gyrus to have the highest weight in differentiating tumor patients based on seizures for three distinct COIs [GM, total volume, and CSF volume] and white matter, respectively. Left-sided transverse temporal gyrus, left precuneus, left transverse temporal, and left supramarginal gyrus were associated with having the highest weight in the differentiation of seizure vs. non-seizure in tumor patients for morphometrics relating to cortical areas in the pial, inner and mid regions and cortical thickness, respectively. Our study elucidates potential biomarkers for seizure targeting in patients with gliomas and IMs based upon morphometric and volumetric assessments. Amongst the widespread brain regions examined in our cohort, pars orbitalis, supramarginal and temporal gyrus (middle, transverse), and the pre-cuneus contribute a maximal potential for differentiation of seizure patients from non-seizure.
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http://dx.doi.org/10.3389/fneur.2020.00444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273506PMC
May 2020

Deformity correction using proximal hooks and distal screws (PHDSs) improves radiological metrics in adolescent idiopathic scoliosis.

Eur Spine J 2021 03 13;30(3):686-691. Epub 2020 May 13.

Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.

Purpose: Surgical correction for AIS has evolved from all hooks to hybrids or all screw constructs. Limited literature exists reporting outcomes using PHDS for posterior spinal fusion (PSF). This is the largest series in evaluating results of PHDS technique.

Methods: A retrospective review of consecutive AIS patients undergoing PSF by a single surgeon between 2006 and 2015 was performed. All eligible patients met a minimum 2-year follow-up. Patient demographics and radiographical parameters (radiographic shoulder height (RSH), T1 tilt, clavicle angle) at baseline, 6-week and 2-year post-operation were recorded. The primary outcome was difference in RSH from baseline measurements evaluated using repeated measures one-way analysis of variance with Bonferroni correction.

Results: A total of 219 patients (mean age at surgery: 13.68 years; 82% female) were included. The mean follow-up was 41.2 months (range 24-108 months). The RSH was significantly improved from - 14.7 ± 10.38 mm to 8.0 ± 6.9 mm (P < 0.0001). Clavicle angle was improved from 2.13° to 1.31° (P < 0.0001). T1 tilt was improved from 5.6° to 2.2° (P < 0.0001). At last follow-up, 95.8% of patients were shoulder balanced. There was a significant improvement of Cobb angle with an average correction of the upper thoracic curve of 42% and main thoracic curve of 67%.

Conclusion: The PHDS demonstrates the potential for additional shoulder balance improvement. Extension of fusion to structural proximal thoracic spine is the key to success for shoulder balance. It remains to be seen whether these improvements will translate into improved clinical outcomes in the longer term.
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http://dx.doi.org/10.1007/s00586-020-06442-3DOI Listing
March 2021

George Chance and Frank Holdsworth: Understanding Spinal Instability and the Evolution of Modern Spine Injury Classification Systems.

Neurosurgery 2020 06;86(6):E509-E516

Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey.

The concept of spinal cord injury has existed since the earliest human civilizations, with the earliest documented cases dating back to 3000 BC under the Egyptian Empire. Howevr, an understanding of this field developed slowly, with real advancements not emerging until the 20th century. Technological advancements including the dawn of modern warfare producing mass human casualties instigated revolutionary advancement in the field of spine injury and its management. Spine surgeons today encounter "Chance" and "Holdsworth" fractures commonly; however, neurosurgical literature has not explored the history of these physicians and their groundbreaking contributions to the modern understanding of spine injury. A literature search using a historical database, Cochrane, Google Scholar, and PubMed was performed. As needed, hospitals and native universities were contacted to add their original contributions to the literature. George Quentin Chance, a Manchester-based British physician, is well known to many as an eminent radiologist of his time who described the eponymous fracture in 1948. Sir Frank Wild Holdsworth (1904-1969), a renowned British orthopedic surgeon who laid a solid foundation for rehabilitation of spinal injuries under the aegis of the Miners' Welfare Commission, described in detail the management of thoraco-lumbar junctional rotational fracture. The work of these 2 men laid the foundation for today's understanding of spinal instability, which is central to modern spine injury classification and management algorithms. This historical vignette will explore the academic legacies of Sir Frank Wild Holdsworth and George Quentin Chance, and the evolution of spinal instability and spine injury classification systems that ensued from their work.
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http://dx.doi.org/10.1093/neuros/nyaa081DOI Listing
June 2020

Lazarus phenomenon in trauma.

Trauma Case Rep 2020 Feb 8;25:100280. Epub 2020 Jan 8.

Department of Emergency Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, United States.

Lazarus phenomenon embodies auto-resuscitation, aka the return of spontaneous circulation following termination of cardiopulmonary resuscitation. Limited or no literature exists that describes auto-resuscitation in trauma. In the current report, we describe a case of an older woman that presented with poly-traumatic injuries following a motor vehicle collision. The aggressive resuscitation efforts failed, and the patient witnessed a pulseless electrical activity; however, nine-minutes after cessation of resuscitation efforts, the patient experienced auto-resuscitation. In addition to the sequel of events following the presentation, the report highlights the management dilemma and ethical implications relating to the observation period for auto-resuscitation in cases of donation after circulatory death, where the urgency to harvest the organs to ensure maximum viability is in direct opposition to ensuring enough time has elapsed to rule out auto-resuscitation. Guidelines on an appropriate period for observation in auto-resuscitation patients queued for organ donation are warranted, keeping in lieu viability of organs following death.
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http://dx.doi.org/10.1016/j.tcr.2020.100280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6950944PMC
February 2020

Medicaid payer status and other factors associated with hospital length of stay in patients undergoing primary lumbar spine surgery.

Clin Neurol Neurosurg 2020 01 24;188:105570. Epub 2019 Oct 24.

Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA. Electronic address:

Objective: The Medicaid patient population and health care costs for spine surgeries among these patients have increased since 2010. Hospital length of stay (LOS) contributes appreciably to hospital costs for patients undergoing primary lumbar spine surgery (PLSS). The aim of this study was to identify independent risk factors for increased LOS in patients undergoing PLSS.

Patients And Methods: In a single-center retrospective study, we reviewed demographic and clinical data from electronic medical records for 181 consecutive adult patients who underwent PLSS involving 1-3 levels from July 2014 to July 2017. We performed regression analyses to identify independent risk factors for increased LOS and to quantify their effects as percent changes in LOS.

Results: Among 181 patients who underwent PLSS, the mean LOS was 3.57 days. Based on the Charlson Comorbidity Index (CCI) and American Society of Anesthesiologist (ASA) classification, patients with Medicaid insurance were healthier than non-Medicaid patients (mean CCI: 0.34 versus 0.65; p = 0.041, ASA: 1.71 versus 1.91; p = 0.046) yet Medicaid patients had a longer LOS compared with non-Medicaid patients (mean LOS: 4.03 versus 3.30 days; p = 0.047). There was no significant difference in discharge disposition between Medicaid and non-Medicaid patients (Home = 82.35 % versus 79.65 %; p = 0.855). Medicaid patients also had significantly less spinal levels involved in their surgery (1.44 versus 1.67; p = 0.027). Multivariable regression modeling identified independent risk factors positively associated with increased LOS as age (+1.0 % per year; p = 0.007), Medicaid insurance status (+28.7 %; p = 0.007), and CCI (10.1 % per increment in CCI; p = 0.030). Fusion surgery also was an independent risk factor for increased LOS when compared with laminectomy (-54.1 %; p < 0.001) or discectomy (-51.3 %; p < 0.001).

Conclusions: Increasing age, Medicaid insurance status, higher CCI, and fusion surgery were independently associated with increased LOS after PLSS. This information is useful for preoperative patient counseling, shared decision-making, and risk stratification and may help to further ongoing discussion regarding contributors to rising health care costs. Findings of increased LOS among Medicaid patients will help direct efforts to identify factors that contribute to this health care expense.
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http://dx.doi.org/10.1016/j.clineuro.2019.105570DOI Listing
January 2020

What Are the Costs of Cervical Radiculopathy Prior to Surgical Treatment?

Spine (Phila Pa 1976) 2019 Jul;44(13):937-942

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Study Design: Retrospective, observational study.

Objective: To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF).

Summary Of Background Data: While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery.

Methods: The Humana claims dataset (2007-2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention.

Results: Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193).

Conclusion: The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002983DOI Listing
July 2019

Preoperative Chronic Opioid Therapy Negatively Impacts Long-term Outcomes Following Cervical Fusion Surgery.

Spine (Phila Pa 1976) 2019 Sep;44(18):1279-1286

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA.

Study Design: Retrospective, observational.

Objective: The aim of this study was to define the impact of preoperative chronic opioid therapy (COT) on outcomes following cervical spine fusions.

Summary Of Background Data: Opioid therapy is a commonly practiced method to control acute postoperative pain. However, concerns exist relating to use of prescription opioids, including inherent risk of abuse, tolerance, and inferior outcomes following major surgery.

Methods: A commercial dataset was queried from 2007 to 2015 for patients undergoing primary cervical spine arthrodesis [ICD-9 codes 81.01-81.03]. Primary outcome measures were 1-year and 2-year reoperation rates, emergency department (ED) visits, adverse events, and prolonged postoperative opioid use. Secondary outcomes included short-term outcomes including 90-day complications (cardiac, renal, neurologic, infectious, etc.). COT was defined as a history of opioid prescription filling within 3 months before surgery and was the primary exposure variable of interest. Generalized linear models investigated the association of preoperative COT on primary/secondary endpoints following risk-adjustment.

Results: Overall, 20,730 patients (51.3% female; 85.9% >50 years) underwent primary cervical spine arthrodesis. Of these, 10,539 (n = 50.8%) met criteria for COT. Postoperatively, 75.3% and 29.8% remained on opioids at 3 months and 1 year. Multivariable models identified an association between COT and an increased risk of 90-day ED visit [odds ratio (OR): 1.25; P < 0.001] and wound complications (OR: 1.24; P = 0.036). At 1 year, COT was strongly associated with reoperations (OR: 1.17; P = 0.043), ED visits (OR: 1.31; P < 0.001), and adverse events including wound complications (OR: 1.32; P < 0.001), infections (OR: 1.34; P = 0.042), constipation (OR: 1.11; P = 0.032), neurological complications (OR: 1.44; P = 0.01), acute renal failure (OR: 1.24; P = 0.004), and venous thromboembolism (OR: 1.20; P = 0.008). At 2 years, COT remained a significant risk factor for additional long-term negative outcomes such as reoperations, including adjacent segment disc disease (OR: 1.21; P = 0.005), ED visits (OR: 1.32; P < 0.001), and other adverse events. Preoperative COT was associated with prolonged postoperative narcotic use at 3 months (OR: 1.30; P < 0.001), 1 year (OR: 5.17; P < 0.001), and at 2 years (OR: 5.75; P < 0.001) after cervical arthrodesis.

Conclusion: Preoperative COT is a modifiable risk factor that is strongly associated with prolonged postoperative opioid use. In addition, COT was associated with inferior short-term and long-term outcomes after cervical spine fusion.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003064DOI Listing
September 2019

Natural History of De Novo Aneurysm Formation in Patients with Treated Aneurysmatic Subarachnoid Hemorrhage: A Ten-Year Follow-Up.

World Neurosurg 2019 Feb 12;122:e291-e295. Epub 2018 Oct 12.

Department of Neurosurgery, University Hospital Duesseldorf, Duesseldorf, Germany.

Background: De novo aneurysm formation after completely occluded aneurysms via clipping or coiling has not been well studied. Although known to occur several years after initial aneurysm management, the natural history of de novo aneurysms is obscure. We investigated the formation of new aneurysms in patients who had previously undergone treatment of intracranial aneurysms.

Methods: In a retrospective, single-institutional series, eligible patients who had undergone treatment of ruptured cerebral aneurysms from 2000 to 2011 were included. The primary outcome measure was the development of de novo aneurysms during long-term follow-up.

Results: Overall, 130 patients (63% women) who had undergone microsurgical clipping (n = 63; 48.5%) or endovascular coiling (n = 67%; 51.5%) for ruptured aneurysms were included. The average follow-up time for our cohort was 10 ± 2.7 years. De novo aneurysms occurred in 10 of 130 patients (7.7%), with a mean time of 7.9 years for aneurysm detection. No association between the formation of de novo aneurysms and the location of the treated aneurysms, smoking status, hypertension, age, or gender was found. Follow-up imaging studies were performed every 2 years. De novo aneurysms had formed in 2 patients within 2-5 years, 7 patients after 5-10 years, and 1 patient after 10 years of follow-up. In 2 of 10 patients, the de novo aneurysm had ruptured and led to subarachnoid haemorrhage.

Conclusion: The rate of de novo aneurysm occurrence was 7.6%, with a mean time to development of 7.9 years. This underscores the significance of long-term monitoring of patients with intracranial aneurysms. In our series, most new aneurysms had occurred after 5 years of follow-up.
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http://dx.doi.org/10.1016/j.wneu.2018.10.022DOI Listing
February 2019

The impact of location on the prognosis of squamous cell carcinomas of the anorectal region.

J Surg Res 2018 11 21;231:173-178. Epub 2018 Jun 21.

Department of Surgery, University of Iowa Hospitals & Clinics, Iowa City, Iowa. Electronic address:

Background: Because anal and rectal squamous cell carcinomas (R-SCCs and A-SCCs) share a common histology and an excellent response to chemoradiation, we hypothesized that R-SCC and A-SCC may represent a similar biological entity, and location would not affect clinical presentation and prognosis.

Methods: Patients diagnosed with R-SCC (n = 2881) and A-SCC (n = 21,854) were identified in the Surveillance, Epidemiology, and End Results database (1998-2013). R-SCCs were staged based on American Joint Committee on Cancer classification for A-SCC, and impact of location was analyzed accordingly.

Results: Compared to A-SCC, R-SCCs were more common in females (65% versus 48%, P < 0.001) and older patients (62 versus 56 yrs, P < 0.001). R-SCC presented with more advanced disease than A-SCC: mean size 4.2 versus 3.6 cm; T4 14% versus 5%; nodal involvement 20% versus 15%; and metastases 13% versus 6% (all P < 0.001). In multivariable analysis, R-SCCs and A-SCCs had similar disease-specific survival (DSS) for stages 0, I, and III; however, stage II R-SCC had significantly worse DSS than A-SCCs (P = 0.002). This was due to a greater proportion of T3 (>5 cm) R-SCC tumors (36% versus 27%, P < 0.001), which had a lower DSS than T2 (2-5 cm) tumors. Within T3 and T4 tumors, R-SCCs had lower DSS than A-SCCs.

Conclusions: R-SCC presented with higher stages than A-SCC, suggesting a delayed diagnosis. Larger R-SCC (T3-T4) had worse survival compared to T3-4 A-SCC, which may be due to a combination of more advanced disease within-stage as well as the use of less efficacious therapeutic regimens. Therefore, location may represent a significant prognostic factor for SCC of the anorectal region.
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http://dx.doi.org/10.1016/j.jss.2018.05.050DOI Listing
November 2018

Point of View: Initial Provider Specialty Is Associated With Long-Term Opiate Use in Patients With Newly Diagnosed Low Back and Lower Extremity Pain.

Spine (Phila Pa 1976) 2019 Feb;44(3):219

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA.

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http://dx.doi.org/10.1097/BRS.0000000000002821DOI Listing
February 2019

Preparing for Bundled Payments in Cervical Spine Surgery: Do We Understand the Influence of Patient, Hospital, and Procedural Factors on the Cost and Length of Stay?

Spine (Phila Pa 1976) 2019 03;44(5):334-345

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA.

Study Design: Retrospective, observational study.

Objective: To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS).

Summary Of Background Data: Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability.

Methods: A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated.

Results: In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05.

Conclusion: Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002825DOI Listing
March 2019

Opioid Utilization Following Lumbar Arthrodesis: Trends and Factors Associated With Long-term Use.

Spine (Phila Pa 1976) 2018 09;43(17):1208-1216

Spine Surgery, Department of Orthopedics and Rehabilitation, University of Iowa Hospitals & Clinics, Iowa City, IA.

Study Design: A retrospective, observational cohort study.

Objective: In patients undergoing lumbar spine arthrodesis, we sought to establish perioperative trends in chronic versus naive opioid users (OUs) and identify modifiable risk factors associated with prolonged consumption.

Summary Of Background Data: The morbidity associated with excessive opioid use for chronic conditions continues to climb and has been identified as a national epidemic. Limiting excessive perioperative opioid use after procedures such as lumbar fusion remains a national health strategy.

Methods: A national commercial claims dataset (2007-2015) was queried for all patients undergoing anterior lumbar interbody fusion (ALIF) and/or lumbar [posterior/transforaminal lumbar interbody fusion (P/TLIF) or posterolateral fusion (PLF)] spinal fusion procedures. Patients were labeled as either an OU (prescription within 3 months pre-surgery) or opioid naive (ON, no prescription). Rates of opioid use were evaluated preoperatively for OU, and longitudinally tracked up to 1-year postoperatively for both OU and ON. Multivariable regression techniques investigated factors associated with opioid use at 1-year following surgery. In addition, a clinical calculator (app) was created to predict 1-year narcotic use.

Results: Overall, 26,553 patients (OU: 58.3%) underwent lumbar surgery (ALIF: 8.5%; P/TLIF: 43.8%; PLF: 41.5%; ALIF+PLF: 6.2%). At 1-month postop, 60.2% ON and 82.9% OUs had a filled opioid prescription. At 3 months, prescription rates declined significantly to 13.9% in ON versus 53.8% in OUs, while plateauing at 6 to 12-month postoperative period (ON: 8.4-9.6%; OU: 42.1-45.3%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs than in ON (42.4% vs. 8.6%; P < 0.001). Preoperative opioid use was the strongest driver of 1-year narcotic use following ALIF [odds ratio (OR): 7.86; P < 0.001], P/TLIFs (OR: 4.62; P < 0.001), or PLF (OR: 7.18; P < 0.001).

Conclusion: Approximately one-third patients chronically use opioids before lumbar arthrodesis and nearly half of the pre-op OUs will continue to use at 1 year. Our findings serve as a baseline in identifying patients at risk for chronic use and alter surgeons to work toward discontinuation of opioids before lumbar spinal surgery.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002734DOI Listing
September 2018

Inpatient Outcomes After Elective Lumbar Spinal Fusion for Patients with Human Immunodeficiency Virus in the Absence of Acquired Immunodeficiency Syndrome.

World Neurosurg 2018 Aug 28;116:e913-e920. Epub 2018 May 28.

Department of Orthopaedic Surgery, University of Miami Hospital, Miami, Florida, USA.

Background: To our knowledge, no prior study has evaluated outcomes after elective lumbar spinal surgery in human immunodeficiency virus (HIV) patients without acquired immunodeficiency syndrome (AIDS). This review investigated the impact of HIV-positive status (without AIDS) on outcomes after elective lumbar fusion for degenerative disc disease (DDD).

Methods: Adult patients registered in the Nationwide Inpatient Sample (2002-2011) undergoing elective lumbar fusion for DDD were extracted. Multivariable regression techniques were used to explore the association of HIV positivity with outcomes after lumbar fusion.

Results: This cohort included 612,000 hospitalizations (0.07% were HIV positive) of lumbar fusion for DDD. Compared with HIV-negative patients undergoing lumbar fusion, HIV-positive patients were younger (47 vs. 55 years), male (61% vs. 42%), largely insured by Medicare (30% vs. 5%), and had higher rates of chronic obstructive pulmonary disease (23.7% vs. 14.6%) (all P < 0.001) but had lower rates of obesity, hypertension, and diabetes (all P < 0.001). Multivariable models demonstrated HIV positivity to be associated with higher odds for an adverse event (odds ratio [OR], 1.92; P < 0.001), in-hospital mortality (OR, 39.91; P < 0.001), wound complications (OR, 2.60; P = 0.004), respiratory (OR, 5.43; P < 0.001) and neurologic (OR, 1.96; P = 0.039) complications, and higher costs (7.1% higher; P = 0.011) compared with non-HIV patients. There were no differences in thromboembolic events, cardiac or gastrointestinal complications, discharge disposition, or length of stay.

Conclusions: Even in this selected cohort of well-controlled HIV patients, there were high complications, with concerning rates of death and respiratory complications. These data shed new light on elective spine surgery in HIV patients and may influence the treatment algorithm of surgeons who are familiar with older papers.
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http://dx.doi.org/10.1016/j.wneu.2018.05.128DOI Listing
August 2018

An Analysis of Publication Productivity During Residency for 1506 Neurosurgical Residents and 117 Residency Departments in North America.

Neurosurgery 2019 04;84(4):857-867

Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.

Background: Bibliometrics is defined as the study of statistical and mathematical methods used to quantitatively analyze scientific literature. The application of bibliometrics in neurosurgery continues to evolve.

Objective: To calculate a number of publication productivity measures for almost all neurosurgical residents and departments within North America. These measures were correlated with survey results on the educational environment within residency programs.

Methods: During May to June 2017, data were collected from departmental websites and Scopus to compose a bibliometric database of neurosurgical residents and residency programs. Data related to authorship value and study content were collected on all articles published by residents. A survey of residency program research and educational environment was administered to program directors and coordinators; results were compared with resident academic productivity.

Results: The median number of publications in residency was 3; median h-index and Resident index were 1 and 0.17 during residency, respectively. There was a statistically significant difference in academic productivity among male neurosurgical residents compared with females. The majority of articles published were tier 1 clinical articles. Residency program research support was significantly associated with increased resident productivity (P < .001). Scholarly activity requirements were not associated with increased resident academic productivity.

Conclusion: This study represents the most comprehensive bibliometric assessment of neurosurgical resident academic productivity during training to date. New benchmarks for individual and department academic productivity are provided. A supportive research environment for neurosurgical residents is associated with increased academic productivity, but a scholarly activity requirement was, surprisingly, not shown to have a positive effect.
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http://dx.doi.org/10.1093/neuros/nyy217DOI Listing
April 2019

Opioid use following cervical spine surgery: trends and factors associated with long-term use.

Spine J 2018 11 10;18(11):1974-1981. Epub 2018 Apr 10.

Orthopaedic Surgery, Columbia University Medical Center, The Spine Hospital, New York-Presbyterian Healthcare System, New York, NY 10034, USA.

Background Context: Limited or no data exist evaluating risk factors associated with prolonged opioid use following cervical arthrodesis.

Purpose: The objectives of this study were to assess trends in postoperative narcotic use among preoperative opioid users (OUs) versus non-opioid users (NOUs) and to identify factors associated with postoperative narcotic use at 1 year following cervical arthrodesis.

Study Design/setting: This is a retrospective observational study.

Patient Sample: The patient sample included 17,391 patients (OU: 52.4%) registered in the Humana Inc claims dataset who underwent anterior cervical fusion (ACF) or posterior cervical fusion (PCF) between 2007 and 2015.

Outcome Measures: Prolonged opioid usage was defined as narcotic prescription filling at 1 year following cervical arthrodesis.

Methods: Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3 months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and trended for 1 year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at 1 year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis (http://neuro-risk.com/opiod-use/ or https://www.neurosurgerycost.com/opioid/opioid_use).

Results: Overall, 87.4% of the patients (n=15,204) underwent ACF, whereas 12.6% (n=2187) underwent PCF. At 1 month following surgery, 47.7% of NOUs and 82% of OUs had a filled opioid prescription. Rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs at 3 months, but plateaued at the 6- to 12-month postoperative period (NOU: 5.7%-6.7%, OU: 44.9%-46.9%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs compared with NOUs (45.3% vs. 6.3%, p<.001). Preoperative opioid use was a significant driver of 1-year narcotic use following ACF (odds ratio [OR]: 7.02, p<.001) and PCF (OR: 6.98, p<.001), along with younger age (≤50 years), history of drug dependence, and lower back pain.

Conclusions: Over 50% of the patients used opioids before cervical arthrodesis. Postoperative opioid use fell dramatically during the first 3 months in NOU, but nearly half of the preoperative OUs will remain on narcotics at 1 year postoperatively. Our findings serve as a baseline in identifying patients at risk of chronic use and encourage discontinuation of opioids before cervical spine surgery.
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http://dx.doi.org/10.1016/j.spinee.2018.03.018DOI Listing
November 2018

Point of View on: "Predicting Likelihood of Surgery Prior to First Visit in Patients With Back and Lower Extremity Symptoms": "A Simple Mathematical Model Based on Over 8,000 Patients".

Spine (Phila Pa 1976) 2018 09;43(18):1306

Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

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http://dx.doi.org/10.1097/BRS.0000000000002642DOI Listing
September 2018

Impact of Psychiatric Comorbidities on Short-Term Outcomes Following Intervention for Lumbar Degenerative Disc Disease.

Spine (Phila Pa 1976) 2018 Oct;43(19):1363-1371

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA.

Study Design: Retrospective, observational cohort study.

Objective: To investigate the impact of psychiatric diseases on short-term outcomes in patients undergoing fusion surgery for lumbar degenerative disc disease (LDDD).

Summary Of Background Data: Limited literature exists on the prevalence and impact of psychiatric comorbidities on outcomes in patients undergoing surgery for LDDD.

Methods: Adult patients (>18 yr) registered in the Nationwide Inpatient Sample database (2002-2011) and undergoing an elective spine fusion for LDDD that met inclusion criteria formed the study population. Defined primary outcome measures were discharge disposition, length of stay, hospitalization cost, and short-term postsurgical complications (neurological, respiratory, cardiac, gastrointestinal, wound complication and infections, venous thromboembolism, and acute renal failure). Multivariable regression techniques were used to explore the association of psychiatric comorbidities on short-term outcomes by adjusting for patient demographics, clinical, and hospital characteristics.

Results: Of the 126,044 adult patients undergoing fusion surgery for LDDD (mean age: 54.91 yr, 58% female) approximately 18% had a psychiatric disease. Multivariable regression analysis revealed patients with psychiatric disease undergoing fusion surgery have higher likelihood for unfavorable discharge (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.35-1.47; P < 0.001), length of stay (OR 1.03; 95% CI 1.02-1.04; P < 0001), postsurgery neurologic complications (OR 1.25; 95% CI 1.13-1.37; P < 0.001), venous thromboembolic events (OR 1.38 95% CI 1.26-1.52; P < 0.001), and acute renal failure (OR 1.17; 95% CI 1.01-1.37; P = 0.040). Patients with psychiatric disease were also associated to have higher hospitalization cost (6.3% higher; 95% CI: 5.6%-7.1%; P < 0.001) compared to those without it.

Conclusion: Our study quantifies the estimates for presence of concomitant psychiatric comorbid conditions on short outcomes in patients undergoing fusions for LDDD. The data provide supporting evidence for adequate preoperative planning and postsurgical care including consultation for mental health for favorable outcomes.

Level Of Evidence: 4.
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http://dx.doi.org/10.1097/BRS.0000000000002616DOI Listing
October 2018

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

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

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

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

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

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

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

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

One-piece Orbitozygomatic Craniotomy for Resection of Rathke's Cleft Cyst: Operative Video.

J Neurol Surg B Skull Base 2018 Feb 11;79(2):S211-S212. Epub 2018 Jan 11.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States.

 The video stars orbitozygomatic resection of Rathke's cleft cyst with suprasellar extension in a 37-year-old male patient presenting with severe headaches and bitemporal hemianopia. Clinical and radiological characteristics along with surgical technique (positioning, bony opening, surgical dissection and debulking, closure), histopathology, and postoperative course are described.  Preoperative MRI demonstrated a noncontrast-enhancing cystic lesion in the sella with suprasellar extension causing compression of both optic nerves. A one-piece orbitozygomatic craniotomy was performed. The tumor was encountered in the interoptic space. First, the cyst was decompressed and fluid appearing like motor oil was aspirated. Both optic nerves were decompressed and dissected free from the cyst wall. Intraoperatively, the most challenging aspect was separating the tumor from surrounding vascular structures, including bilateral A1 arteries and the left carotid bifurcation. A combination of sharp and blunt dissection was utilized to free the tumor from adhesions to critical neurovascular structures. Once freed, the suprasellar aspect of the tumor was mobilized into the operative cavity and debulked. Finally, the sellar component of the tumor was removed all the way down to the sellar floor. Postoperative MRI demonstrated decompressed bilateral optic nerves with an intact pituitary stalk with preservation of normal pituitary gland. Histopathology identified pathognomonic features consistent with diagnosis of Rathke's cleft cyst, including flattened ciliated epithelium and presence of Rathke's cleft remnants.  Postoperatively, bilateral improvement in vision was noted with transient diabetes insipidus. Patient was discharged home on postoperative day 4.  A one-piece orbitozygomatic craniotomy is an effective and safe strategy for resection of Rathke's cleft cysts with suprasellar extension. The link to the video can be found at: https://youtu.be/-Yqtcd2gLSs .
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http://dx.doi.org/10.1055/s-0037-1620277DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5796882PMC
February 2018

Proposing a validated clinical app predicting hospitalization cost for extracranial-intracranial bypass surgery.

PLoS One 2017 27;12(10):e0186758. Epub 2017 Oct 27.

Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, United States of America.

Object: United States healthcare reforms are focused on curtailing rising expenditures. In neurosurgical domain, limited or no data exists identifying potential modifiable targets associated with high-hospitalization cost for cerebrovascular procedures such as extracranial-intracranial (ECIC) bypass. Our study objective was to develop a predictive model of initial cost for patients undergoing bypass surgery.

Methods: In an observational cohort study, we analyzed patients registered in the Nationwide Inpatient Sample (2002-2011) that underwent ECIC bypass. Split-sample 1:1 randomization of the study cohort was performed. Hospital cost data was modelled using ordinary least square to identity potential drivers impacting initial hospitalization cost. Subsequently, a validated clinical app for estimated hospitalization cost is proposed (https://www.neurosurgerycost.com/calc/ec-ic-by-pass).

Results: Overall, 1533 patients [mean age: 45.18 ± 19.51 years; 58% female] underwent ECIC bypass for moyamoya disease [45.1%], cerebro-occlusive disease (COD) [23% without infarction; 12% with infarction], unruptured [12%] and ruptured [4%] aneurysms. Median hospitalization cost was $37,525 (IQR: $16,225-$58,825). Common drivers impacting cost include Asian race, private payer, elective admission, hyponatremia, neurological and respiratory complications, acute renal failure, bypass for moyamoya disease, COD without infarction, medium and high volume centers, hospitals located in Midwest, Northeast, and West region, total number of diagnosis and procedures, days to bypass and post-procedural LOS. Our model was validated in an independent cohort and using 1000-bootstrapped replacement samples.

Conclusions: Identified drivers of hospital cost after ECIC bypass could potentially be used as an adjunct for creation of data driven policies, impact reimbursement criteria, aid in-hospital auditing, and in the cost containment debate.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0186758PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5659612PMC
November 2017

Supraorbital Approach for Resection of Clinoidal Meningioma.

World Neurosurg 2018 Jan 13;109:295. Epub 2017 Oct 13.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA. Electronic address:

Meningiomas of the clinoid region pose a formidable surgical challenge. Pterional craniotomy is the traditional approach and is often associated with high-risk postsurgical morbidities. In the current presentation, we describe an elderly male with a clinoidal meningioma who underwent a minimally invasive supraorbital craniotomy for tumor resection. Patient presentation, neuroimaging, and surgical techniques (patient position, incision, anatomic consideration, and surgical steps) are described meticulously. Initial intraoperative steps include dissection via the corridor between the carotid artery and the tentorium, as well as exposing the tumor in the opticocarotid triangle, followed by tumor dissection using microsurgical techniques. Care must be taken to preserve the supraorbital nerve to prevent frontal numbness and avoid violation of the frontal sinus to prevent postoperative cerebrospinal fluid leak. Emphasis on using this minimally invasive procedure for clinoidal meningiomas over the pterional approach for a select cohort of patients is laid, considering the cosmetic merits and adequate extent of tumor resection.
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http://dx.doi.org/10.1016/j.wneu.2017.10.019DOI Listing
January 2018

Resection of posterior clinoid meningioma through retrosigmoid approach: concepts and nuances.

Neurosurg Focus 2017 Oct;43(VideoSuppl2):V5

Department of Neurosurgery, LSU Health Science Center, Shreveport, Louisiana.

Meningiomas arising from the posterior clinoid process pose a great surgical challenge because of their location and propensity to cause critical neurovascular compression. The authors' patient was a 66-year-old female who had a large posterior clinoid meningioma with significant brainstem compression that was operated on through the retrosigmoid approach. This 3D surgical video emphasizes the various technical concepts that are important to preserving compressed neural and vascular structures during the surgery. It would also be interesting to note the extent of visualization around the posterior clinoid region gained through a retrosigmoid corridor. The video can be found here: https://youtu.be/CBmT_0ov0YA .
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http://dx.doi.org/10.3171/2017.10.FocusVid.17325DOI Listing
October 2017

Adolescent idiopathic scoliosis: risk factors for complications and the effect of hospital volume on outcomes.

Neurosurg Focus 2017 Oct;43(4):E3

Department of Neurosurgery, Louisiana State University Health Sciences Center-Shreveport.

OBJECTIVE Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Limited literature exists defining risk factors associated with outcomes during initial hospitalization in these patients. In this study, the authors investigated patient demographics, clinical and hospital characteristics impacting short-term outcomes, and costs in adolescent patients undergoing surgical deformity correction for idiopathic scoliosis. Additionally, the authors elucidate the impact of hospital surgical volume on outcomes for these patients. METHODS Using the National Inpatient Sample database and appropriate International Classification of Diseases, 9th Revision codes, the authors identified adolescent patients (10-19 years of age) undergoing surgical deformity correction for idiopathic scoliosis during 2001-2014. For national estimates, appropriate weights provided by the Agency of Healthcare Research and Quality were used. Multivariable regression techniques were employed to assess the association of risk factors with discharge disposition, postsurgical neurological complications, length of hospital stay, and hospitalization costs. RESULTS Overall, 75,106 adolescent patients underwent surgical deformity correction. The rates of postsurgical complications were estimated at 0.9% for neurological issues, 2.8% for respiratory complications, 0.8% for cardiac complications, 0.4% for infections, 2.7% for gastrointestinal complications, 0.1% for venous thromboembolic events, and 0.1% for acute renal failure. Overall, patients stayed at the hospital for an average of 5.72 days (median 5 days) and on average incurred hospitalization costs estimated at $54,997 (median $47,909). As compared with patients at low-volume centers (≤ 50 operations/year), those undergoing surgical deformity correction at high-volume centers (> 50/year) had a significantly lower likelihood of an unfavorable discharge (discharge to rehabilitation) (OR 1.16, 95% CI 1.03-1.30, p = 0.016) and incurred lower costs (mean $33,462 vs $56,436, p < 0.001) but had a longer duration of stay (mean 6 vs 5.65 days, p = 0.002). In terms of neurological complications, no significant differences in the odds ratios were noted between high- and low-volume centers (OR 1.23, 95% CI 0.97-1.55, p = 0.091). CONCLUSIONS This study provides insight into the clinical characteristics of AIS patients and their postoperative outcomes following deformity correction as they relate to hospital volume. It provides information regarding independent risk factors for unfavorable discharge and neurological complications following surgery for AIS. The proposed estimates could be used as an adjunct to clinical judgment in presurgical planning, risk stratification, and cost containment.
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http://dx.doi.org/10.3171/2017.6.FOCUS17300DOI Listing
October 2017

Natalizumab-Associated Primary Central Nervous System Lymphoma.

World Neurosurg 2018 Jan 28;109:152-159. Epub 2017 Sep 28.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA. Electronic address:

Objective: Natalizumab, a selective adhesion molecule inhibitor binding to an α-4 subunit of integrin, has emerged to be an effective immunomodulator, especially in the treatment of relapsing-remitting multiple sclerosis and Crohn disease. Recent reports documenting the development of primary central nervous system lymphoma (PCNSL) as a result of its administration have been concerning, and they trigger a debate about a possible causal association. In our report, we provide a comprehensive review of the literature on lymphoma development after natalizumab use, and we report an additional case of PCNSL development in a young woman who received natalizumab for her Crohn disease.

Methods: A systematic (qualitative) review of literature on lymphoma development after natalizumab therapy was performed by use of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data on patient characteristics, indication for drug therapy, dosages, radiologic findings, potential risk factors for PCNSL, and tumor markers were synthesized. Additionally, we present the findings from the case of a young woman who received natalizumab therapy (4 doses, 300 mg each) for Crohn disease and in whom PCNSL developed.

Results: Overall, 8 reports including our index case document lymphoma development after natalizumab use. Our case finding revisits the debate suggesting a remote possibility of association that warrants further evaluation and validation.

Conclusions: Evidence documenting a causal association of natalizumab and PCNSL is weak. Considering the potential benefits of using natalizumab for current indications, we recommend vigilant monitoring of patients receiving the drug for PCNSL outlook.
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http://dx.doi.org/10.1016/j.wneu.2017.09.131DOI Listing
January 2018

Impact of Hospital Caseload and Elective Admission on Outcomes After Extracranial-Intracranial Bypass Surgery.

World Neurosurg 2017 Dec 21;108:716-728. Epub 2017 Sep 21.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA. Electronic address:

Background: Limited information exists evaluating the impact of hospital caseload and elective admission on outcomes after patients have undergone extracranial-intracranial (ECIC) bypass surgery. Using the Nationwide Inpatient Sample (NIS) for 2001-2014, we evaluated the impact of hospital caseload and elective admission on outcomes after bypass.

Methods: In an observational cohort study, weighted estimates were used to investigate the association of hospital caseload and elective admission on short-term outcomes after bypass surgery using multivariable regression techniques.

Results: Overall, 10,679 patients (mean age, 43.39 ± 19.63 years; 59% female) underwent bypass across 495 nonfederal U.S. hospitals. In multivariable models, patients undergoing bypass at high-volume centers were associated with decreased probability of mortality (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.22-0.70; P < 0.001), length of stay (OR, 0.86; 95% CI, 0.82-0.90; P < 0.001), postbypass neurologic complications (OR, 0.66; 95% CI, 0.49-0.89; P = 0.007), venous thromboembolism (OR, 0.69; 95% CI, 0.49-0.97; P = 0.033), and acute renal failure (OR, 0.45; 95% CI, 0.26-0.80; P = 0.007), and higher hospitalization cost (26.3% higher) compared with low-volume centers. Likewise, patients undergoing elective bypass were associated with decreased likelihood of mortality (OR, 0.38; 95% CI, 0.25-0.59; P < 0.001), unfavorable discharge (OR, 0.57; 95% CI, 0.43-0.76; P < 0.001), length of stay (OR, 0.62; 95% CI, 0.59-0.64; P < 0.001), venous thromboembolism (OR, 0.61; 95% CI, 0.49-0.77; P < 0.001), acute renal failure (OR, 0.64; 95% CI, 0.43-0.94; P = 0.022), wound complications (OR, 0.71; 95% CI, 0.53-0.96; P = 0.028), and lower hospitalization cost (34.5% lower) compared with nonelective admissions.

Conclusions: Our findings serve as a framework for strengthening referral networks for complex cases to centers performing high volumes of cerebral bypass. Also, our study supports improved outcomes in select patients undergoing elective bypass procedures.
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http://dx.doi.org/10.1016/j.wneu.2017.09.082DOI Listing
December 2017

Primary pituitary abscess in preadolescence mimicking a sellar mass.

Neurol India 2017 Sep-Oct;65(5):1167-1169

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.

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http://dx.doi.org/10.4103/neuroindia.NI_997_16DOI Listing
July 2019

Impact of Prehospital Transportation on Survival in Skiers and Snowboarders with Traumatic Brain Injury.

World Neurosurg 2017 Aug 27;104:909-918.e8. Epub 2017 May 27.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA.

Introduction: Prehospital helicopter use and its impact on outcomes in snowboarders and skiers incurring traumatic brain injury (TBI) is unknown. The present study investigates the association of helicopter transport with survival of snowboarders and skiers with TBI, in comparison with ground emergency medical services (EMS), by using data derived from the National Trauma Data Bank (2007-2014).

Methods: Primary and secondary endpoints were defined as in-hospital survival and absolute risk reduction based upon number needed to transport (treat) respectively. Multivariable regression models including traditional logit model, model fitted with generalized estimating equations, and those incorporating results from propensity score matching methods were used to investigate the association of helicopter transport with survival compared with ground EMS.

Results: Of the 1018 snowboarders and skiers who met the criteria, 360 (35.4%) were transported via helicopters whereas 658 (64.6%) via ground EMS with a mortality rate of 1.7% and 1.5%, respectively. Multivariable log-binomial models demonstrated association of prehospital helicopter transport with increased survival (odds ratio 8.58; 95% confidence interval 1.09-67.64; P = 0.041; absolute risk reduction: 10.06%). This finding persisted after propensity score matching (odds ratio 24.73; 95% confidence interval 5.74-152.55; P < 0.001). The corresponding absolute risk reduction implies that approximately 10 patients need to be transported via helicopter to save 1 life.

Conclusions: Based on our robust statistical analysis of retrospective data, our findings suggest prehospital helicopter transport improved survival in patients incurring TBI after snowboard- or ski-related falls compared with those transported via ground EMS. Policies directed at using helicopter services at remote winter resorts or ski or snowboarding locations should be implemented.
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http://dx.doi.org/10.1016/j.wneu.2017.05.108DOI Listing
August 2017

William Edward Gallie (1882-1959): father of the Gallie wiring technique for atlantoaxial arthrodesis.

J Neurosurg 2018 03 26;128(3):938-941. Epub 2017 May 26.

William Edward Gallie (1882-1959) was a Canadian general surgeon with special expertise in orthopedic surgery. His experience with surgical management of cervical spine subluxation led him to invent a method of cervical wiring of the atlas to the axis. His method of C1-2 wiring has since been modified, but it still remains one of the three most commonly taught wiring techniques in neurosurgical training programs. Gallie is also hailed for instituting the first surgical training program in Canada, a curriculum his pupils memorialized as the "Gallie course" in surgery. In this historical vignette, the authors describe Gallie's life and depict his contributions to surgery.
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http://dx.doi.org/10.3171/2016.12.JNS161224DOI Listing
March 2018

A Political Case of Penetrating Cranial Trauma: The Injury of James Scott Brady.

Neurosurgery 2017 Sep;81(3):545-551

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana.

James Brady, the White House press secretary during President Ronald Reagan's first term in office, was 1 of 4 people (including the President) wounded during an attempted assassination attempt on President Reagan's life on March 30, 1981. John Hinckley, Jr. was found not guilty of this attempt by reason of insanity. The assassination attempt was a ploy by Hinckley, Jr. to impress the actress Jodie Foster. Brady was the most seriously injured of the 4 who were wounded. He suffered a gunshot wound to the left forehead that traveled through the left frontal lobe, corpus callosum, and then into the right frontal and temporal lobes. He initially required a bifrontal craniotomy for evacuation of a right frontotemporal intraparenchymal hemorrhage and debridement of tract. His postoperative course was complicated by seizures, cerebrospinal fluid leakage (necessitating multiple reparative procedures), aspiration pneumonia, and pulmonary emboli. Despite the severity of his injury and perioperative morbidities, Mr. Brady made good recovery. Although permanently left with residual weakness on the left side of his body, making a wheelchair necessary, Brady maintained cognitive and personality traits that were very close to his preinjury baseline. As a result, James Brady and his wife, Sarah, led a call to create legislative reform subsequently known as the "Brady Bill." This bill controversially made mandatory background checks for the purchase of firearms from licensed dealers. Our work aims to describe the assassination attempt, the neurosurgical injury and management of Mr. Brady's case, and the brief historical sequel that followed.
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http://dx.doi.org/10.1093/neuros/nyx152DOI Listing
September 2017
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