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Curt A, Hsieh J, Schubert M, Hupp M, Friedl S, Freund P, Huber E, Pfyffer D, Sutter R, Jutzeler C, Wüthrich RP, Min K, Casha S, Fehlings MG, Guzman R. The Damaged Spinal Cord Is a Suitable Target for Stem Cell Transplantation. Neurorehabil Neural Repair 2020; 34:758-768. [PMID: 32698674 DOI: 10.1177/1545968320935815] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background. Given individuals with spinal cord injury (SCI) approaching 2 million, viable options for regenerative repair are desperately needed. Human central nervous system stem cells (HuCNS-SC) are self-renewing, multipotent adult stem cells that engraft, migrate, and differentiate in appropriate regions in multiple animal models of injured brain and spinal cord. Preclinical improved SCI locomotor function provided rationale for the first-in-human SCI clinical trial of HuCNS-SC cells. Evidence of feasibility and long-term safety of cell transplantation into damaged human cord is needed to foster translational progression of cellular therapies. Methods. A first-ever, multisite phase I/IIa trial involving surgical transplantation of 20 million HuCNS-SC cells into the thoracic cord in 12 AIS A or B subjects (traumatic, T2-T11 motor-complete, sensory-incomplete), aged 19 to 53 years, demonstrated safety and preliminary efficacy. Six-year follow-up data were collected (sensory thresholds and neuroimaging augmenting clinical assessments). Findings. The study revealed short- and long-term surgical and medical safety (well-tolerated immunosuppression in population susceptible to infections). Preliminary efficacy measures identified 5/12 with reliable sensory improvements. Unfortunately, without thoracic muscles available for manual muscle examination, thoracic motor changes could not be measured. Lower limb motor scores did not change during the study. Cervical cord imaging revealed, no tumor formation or malformation of the lesion area, and secondary supralesional structural changes similar to SCI control subjects. Interpretation. Short- and long-term safety and feasibility support the consideration of cell transplantation for patients with complete and incomplete SCI. This report is an important step to prepare, foster, and maintain the therapeutic development of cell transplantation for human SCI.
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Affiliation(s)
- Armin Curt
- Balgrist University Hospital, Zurich, Switzerland
| | - Jane Hsieh
- Balgrist University Hospital, Zurich, Switzerland
| | | | - Markus Hupp
- Balgrist University Hospital, Zurich, Switzerland
| | | | | | | | | | - Reto Sutter
- Balgrist University Hospital, Zurich, Switzerland
| | | | | | - Kan Min
- Balgrist University Hospital, Zurich, Switzerland
| | - Steve Casha
- University of Calgary, Calgary, Alberta, Canada
| | - Michael G Fehlings
- Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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202
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Furlan JC, Liu Y, Dietrich WD, Norenberg MD, Fehlings MG. Age as a determinant of inflammatory response and survival of glia and axons after human traumatic spinal cord injury. Exp Neurol 2020; 332:113401. [PMID: 32673621 DOI: 10.1016/j.expneurol.2020.113401] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 06/20/2020] [Accepted: 07/09/2020] [Indexed: 01/09/2023]
Abstract
Despite the shift in the demographics of traumatic spinal cord injury (SCI) with increased proportion of injuries in the elderly, little is known on the potential effects of old age on the pathobiology of SCI. Since there is an assumption that age adversely affects neural response to SCI, this study examines the clinically relevant question on whether age is a key determinant of inflammatory response, oligodendroglial apoptosis and axonal survival after traumatic SCI. This unique study includes post-mortem spinal cord tissue from 64 cases of SCI (at cervical or high-thoracic levels) and 38 control cases without CNS injury. Each group was subdivided into subgroups of younger and elderly individuals (65 years of age or older at the SCI onset). The results of this study indicate that age at the SCI onset does not adversely affect the cellular inflammatory response to, oligodendroglial apoptosis and axonal survival after SCI. These results support the conclusion that elderly individuals have similar neurobiological responses to SCI as younger people and, hence, treatment decisions should be based on an assessment of the individual patient and not an arbitrary assumption that "advanced age" should exclude patients with an acute SCI from access to advanced care and translational therapies.
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Affiliation(s)
- Julio C Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada; Lyndhurst Centre, KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada; Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.
| | - Yang Liu
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - W Dalton Dietrich
- Department of Neurological Surgery, Neurology, and Cell Biology & Anatomy, University of Miami, Miami, Florida, USA; Miami Project to Cure Paralysis, Miami, Florida, USA
| | - Michael D Norenberg
- Miami Project to Cure Paralysis, Miami, Florida, USA; Department of Neuropathology, University of Miami, Leonard M. Miller School of Medicine, Miami, Florida, USA
| | - Michael G Fehlings
- Krembil Research Institute, University Health Network, Toronto, Ontario, Canada; Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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203
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Yousefifard M, Nasseri Maleki S, Askarian-Amiri S, Vaccaro AR, Chapman JR, Fehlings MG, Hosseini M, Rahimi-Movaghar V. A combination of mesenchymal stem cells and scaffolds promotes motor functional recovery in spinal cord injury: a systematic review and meta-analysis. J Neurosurg Spine 2020; 32:269-284. [PMID: 31675724 DOI: 10.3171/2019.8.spine19201] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is controversy about the role of scaffolds as an adjunctive therapy to mesenchymal stem cell (MSC) transplantation in spinal cord injury (SCI). Thus, the authors aimed to design a meta-analysis on preclinical evidence to evaluate the effectiveness of combination therapy of scaffold + MSC transplantation in comparison with scaffolds alone and MSCs alone in improving motor dysfunction in SCI. METHODS Electronic databases including Medline, Embase, Scopus, and Web of Science were searched from inception until the end of August 2018. Two independent reviewers screened related experimental studies. Animal studies that evaluated the effectiveness of scaffolds and/or MSCs on motor function recovery following experimental SCI were included. The findings were reported as standardized mean difference (SMD) and 95% confidence interval (CI). RESULTS A total of 34 articles were included in the meta-analysis. Analyses show that combination therapy in comparison with the scaffold group alone (SMD 2.00, 95% CI 1.53-2.46, p < 0.0001), the MSCs alone (SMD 1.58, 95% CI 0.84-2.31, p < 0.0001), and the nontreated group (SMD 3.52, 95% CI 2.84-4.20, p < 0.0001) significantly improved motor function recovery. Co-administration of MSCs + scaffolds only in the acute phase of injury (during the first 3 days after injury) leads to a significant recovery compared to scaffold alone (SMD 2.18, p < 0.0001). In addition, the cotransplantation of scaffolds with bone marrow-derived MSCs (SMD 1.99, p < 0.0001) and umbilical cord-derived MSCs (SMD 1.50, p = 0.001) also improved motor function following SCI. CONCLUSIONS The findings showed that scaffolds + MSCs is more effective than scaffolds and MSCs alone in improving motor function following SCI in animal models, when used in the acute phase of injury.
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Affiliation(s)
- Mahmoud Yousefifard
- 1Physiology Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Solmaz Nasseri Maleki
- 1Physiology Research Center, Faculty of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Alexander R Vaccaro
- 2Department of Orthopedics and Neurosurgery, Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jens R Chapman
- 3Swedish Neuroscience Institute, Swedish Medical Center, Seattle, Washington
| | - Michael G Fehlings
- 4Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,5Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,6Department of Surgery and Spine Program, University of Toronto, Ontario, Canada
| | - Mostafa Hosseini
- 7Department of Epidemiology and Biostatistics, School of Public Health, and
| | - Vafa Rahimi-Movaghar
- 8Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran; and.,9Brain and Spinal Injuries Research Center (BASIR), Neuroscience Institute, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
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204
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Badhiwala JH, Nassiri F, Witiw CD, Mansouri A, Almenawer SA, da Costa L, Fehlings MG, Wilson JR. Investigating the utility of intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion: analysis of over 140,000 cases from the National (Nationwide) Inpatient Sample data set. J Neurosurg Spine 2020; 31:76-86. [PMID: 30925481 DOI: 10.3171/2019.1.spine181110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF. METHODS This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score-matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars). RESULTS A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score-matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges. CONCLUSIONS The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).
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Affiliation(s)
- Jetan H Badhiwala
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Farshad Nassiri
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Christopher D Witiw
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Alireza Mansouri
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Saleh A Almenawer
- 2Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Leodante da Costa
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Jefferson R Wilson
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
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205
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Badhiwala JH, Leung SN, Ellenbogen Y, Akbar MA, Martin AR, Jiang F, Wilson JRF, Nassiri F, Witiw CD, Wilson JR, Fehlings MG. A comparison of the perioperative outcomes of anterior surgical techniques for the treatment of multilevel degenerative cervical myelopathy. J Neurosurg Spine 2020; 33:1-8. [PMID: 32534484 DOI: 10.3171/2020.4.spine191094] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 04/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Multilevel ventral compressive pathology is routinely managed through anterior decompression and reconstruction, but there remains uncertainty regarding the relative safety and efficacy of multiple discectomies, multiple corpectomies, or hybrid corpectomy-discectomy. To that end, using a large national administrative healthcare data set, the authors sought to compare the perioperative outcomes of anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and hybrid corpectomy-discectomy for multilevel DCM. METHODS Patients with a primary diagnosis of DCM who underwent an elective anterior cervical decompression and reconstruction operation over 3 cervical spinal segments were identified from the 2012-2017 National Surgical Quality Improvement Program database. Patients were separated into those undergoing 3-level discectomy, 2-level corpectomy, or a hybrid procedure (single-level corpectomy plus additional single-level discectomy). Outcomes included 30-day mortality, major complication, reoperation, and readmission, as well as operative duration, length of stay (LOS), and routine discharge home. Outcomes were compared between treatment groups by multivariable regression, adjusting for age and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD) and associated 95% confidence interval. RESULTS The study cohort consisted of 1298 patients; of these, 713 underwent 3-level ACDF, 314 2-level ACCF, and 271 hybrid corpectomy-discectomy. There was no difference in 30-day mortality, reoperation, or readmission among the 3 procedures. However, on both univariate and adjusted analyses, compared to 3-level ACDF, 2-level ACCF was associated with significantly greater risk of major complication (aOR 2.82, p = 0.005), longer hospital LOS (aMD 0.8 days, p = 0.002), and less frequent discharge home (aOR 0.59, p = 0.046). In contrast, hybrid corpectomy-discectomy had comparable outcomes to 3-level ACDF but was associated with significantly shorter operative duration (aMD -16.9 minutes, p = 0.002). CONCLUSIONS The authors found multiple discectomies and hybrid corpectomy-discectomy to have a comparable safety profile in treating multilevel DCM. In contrast, multiple corpectomies were associated with a higher complication rate, longer hospital LOS, and lower likelihood of being discharged directly home from the hospital, and may therefore be a higher-risk operation.
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206
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Nouri A, Kato S, Badhiwala JH, Robinson M, Mejia Munne J, Yang G, Jeong W, Nasser R, Gimbel DA, Cheng JS, Fehlings MG. The Influence of Cervical Spondylolisthesis on Clinical Presentation and Surgical Outcome in Patients With DCM: Analysis of a Multicenter Global Cohort of 458 Patients. Global Spine J 2020; 10:448-455. [PMID: 32435566 PMCID: PMC7222678 DOI: 10.1177/2192568219860827] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
STUDY DESIGN Ambispective study with propensity matching. OBJECTIVE To assess the impact of cervical spondylolisthesis (CS) on clinical presentation and surgical outcome in patients with degenerative cervical myelopathy (DCM). METHODS A total of 458 magnetic resonance images (MRIs) from the AOSpine CSM-NA and CSM-I studies were reviewed and CS was identified. Patients with DCM were divided into 2 cohorts, those with CS and those without, and propensity matching was performed. Patient demographics, neurological and functional status at baseline and 2-year follow-up were compared. RESULTS Compared with nonspondylolisthesis (n = 404), CS patients (n = 54) were 8.8 years older (P < .0001), presented with worse baseline neurological and functional status (mJOA [modified Japanese Orthopaedic Association Assessment Scale], P = .008; Nurick, P = .008; SF-36-PCS [Short Form-36 Physical Component Score], P = .01), more commonly presented with ligamentum flavum enlargement (81.5% vs 53.5%, P < .0001), and were less commonly from Asia (P = .0002). Surgical approach varied between cohorts (P = .0002), with posterior approaches favored in CS (61.1% vs 37.4%). CS patients had more operated levels (4.3 ± 1.4 vs 3.6 ± 1.2, P = .0002) and tended to undergo longer operations (196.6 ± 89.2 vs 177.2 ± 75.6 minutes, P = .087). Neurological functional recovery was lower with CS (mJOA [1.5 ± 3.6 vs 2.8 ± 2.7, P = .003]; Nurick [-0.8 ± 1.4 vs -1.5 ± 1.5, P = .002]), and CS was an independent predictor of worse mJOA recovery ratio at 2 years (B = -0.190, P < .0001). After propensity matching, improvement of neurological function was still lower in CS patients (mJOA [1.5 ± 3.6 vs 3.2 ± 2.8, P < .01]; Nurick [-0.8 ± 1.4 vs -1.4 ± 1.6, P = .02]). CONCLUSIONS CS patients are older, present with worse neurological/functional impairment, and receive surgery on more levels and more commonly from the posterior. CS may indicate a more advanced state of DCM pathology and is more likely to result in a suboptimal surgical outcome.
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Affiliation(s)
- Aria Nouri
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - So Kato
- University of Tokyo, Tokyo, Japan
| | | | - Michael Robinson
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Juan Mejia Munne
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - George Yang
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - William Jeong
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rani Nasser
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David A. Gimbel
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph S. Cheng
- University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael G. Fehlings
- University of Toronto, Toronto, Ontario, Canada,Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Michael G. Fehlings, Halbert Chair in Neural Repair and Regeneration, University of Toronto, Head, Spinal Program, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Suite 4W-449, Toronto, Ontario, M5T 2S8, Canada.
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207
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Zavvarian MM, Hong J, Fehlings MG. The Functional Role of Spinal Interneurons Following Traumatic Spinal Cord Injury. Front Cell Neurosci 2020; 14:127. [PMID: 32528250 PMCID: PMC7247430 DOI: 10.3389/fncel.2020.00127] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 04/17/2020] [Indexed: 12/17/2022] Open
Abstract
Traumatic spinal cord injury (SCI) impedes signal transmission by disrupting both the local neurons and their surrounding synaptic connections. Although the majority of SCI patients retain spared neural tissue at the injury site, they predominantly suffer from complete autonomic and sensorimotor dysfunction. While there have been significant advances in the characterization of the spared neural tissue following SCI, the functional role of injury-induced interneuronal plasticity remains elusive. In healthy individuals, spinal interneurons are responsible for relaying signals to coordinate both sympathetic and parasympathetic functions. However, the spontaneous synaptic loss following injury alters these intricate interneuronal networks in the spinal cord. Here, we propose the synaptopathy hypothesis of SCI based on recent findings regarding the maladaptive role of synaptic changes amongst the interneurons. These maladaptive consequences include circuit inactivation, neuropathic pain, spasticity, and autonomic dysreflexia. Recent preclinical advances have uncovered the therapeutic potential of spinal interneurons in activating the dormant relay circuits to restore sensorimotor function. This review will survey the diverse role of spinal interneurons in SCI pathogenesis as well as treatment strategies to target spinal interneurons.
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Affiliation(s)
- Mohammad-Masoud Zavvarian
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - James Hong
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
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208
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Sener A, Anderson CC, Auger FA, Barralet J, Brindle M, Cayabyab FS, Fehlings MG, Lacombe L, Perrault LP, Sabbagh R, Seely AJ, Wallace C, Ellsmere J, Keijzer R. Best practices for enhancing surgical research: a perspective from the Canadian Association of Chairs of Surgical Research. Can J Surg 2020; 62:488-498. [PMID: 31782647 DOI: 10.1503/cjs.012619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Summary The Canadian Association of Chairs of Surgical Research was created in 2014, with representation from every departmental surgical research committee across Canada, to establish Canadian surgical research as a beacon for health care innovation and to propose solutions for the daily challenges facing surgeon-researchers. Our key mandate has been to identify challenges for surgeons and scientists performing research to prevent further erosion of this vital area of activity that benefits patients, health care service providers and Canadian society. This article outlines the findings of a nationwide survey sent to all members of departments of surgery across Canada, seeking input on current threats and potential solutions. The results suggest that surgical research in Canada is experiencing a decline in funding and an increase in challenges affecting research productivity of academic surgeons, such as pressures to be clinically active, unpredictable surgical schedules, growing administrative demands, and increasing complexity of patient populations. Although surgeons are productive in their research endeavours, institutional changes and sharing of best practices are needed to ensure sustainable growth of research programs.
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Affiliation(s)
- Alp Sener
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Colin C. Anderson
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Francois A. Auger
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Jake Barralet
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Mary Brindle
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Francisco S. Cayabyab
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Michael G. Fehlings
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Louis Lacombe
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Louis P. Perrault
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Robert Sabbagh
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Andrew J.E. Seely
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Christopher Wallace
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - James Ellsmere
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
| | - Richard Keijzer
- From the Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, Ont. (Sener); the Department of Surgery, University of Alberta, Edmonton, Alta. (Anderson); the Department of Surgery, Université Laval, Québec, Que. (Auger,Lacombe); the Department of Surgery, McGill University, Montreal, Que. (Barralet); the Department of Surgery, University of Calgary, Calgary, Alta. (Brindle); the Department of Surgery, University of Saskatchewan, Saskatoon, Sask. (Cayabyab); the Department of Surgery, University of Toronto, Toronto, Ont. (Fehlings); the Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Que. (Perrault); the Department of Surgery, Université de Sherbrooke, Sherbrooke, Que. (Sabbagh); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Seely); the Department of Surgery, Queen’s University, Kingston, Ont. (Wallace); the Department of Surgery, Dalhousie University, Halifax, NS (Ellsmere); and the Department of Surgery, University of Manitoba, Winnipeg, Man. (Keijzer)
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Schomacher M, Jiang F, Alrjoub M, Witiw CD, Diamandis P, Fehlings MG. The posterior cervical transdural approach for retro-odontoid mass pseudotumor resection: report of three cases and discussion of the current literature. Eur Spine J 2020; 29:162-170. [PMID: 32296950 DOI: 10.1007/s00586-020-06405-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 03/02/2020] [Accepted: 03/30/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The treatment of a retro-odontoid pseudotumor mass associated with severe spinal cord compression is challenging due to the complex regional anatomy. Here, we present an attractive treatment option involving a single-stage posterior transdural microsurgical resection followed by instrumented cervical reconstruction. METHODS We describe three patients presenting with clinical signs of cervical myelopathy and an imaging finding of mucoid and fibrous soft or semi-soft retro-odontoid pseudotumor mass with significant spinal cord compression at the C1/C2 level. Given the severity of the symptoms, surgical decompression was planned and fusion was necessitated by the severe degenerative osteoarthritis seen at the C1/C2 level with signs of instability. Using a standard posterior approach to the spine, a suboccipital decompression by craniectomy and laminectomy of C1, C2 and C3 was performed. The masses were visualized and confirmed with ultrasound imaging, and intraoperative neurosurgical monitoring was applied. The dura was then opened from the level of C0-C2. Exiting C2-C3 nerve roots were identified and protected throughout the procedure, and the dentate ligament was cut to facilitate access. Incision of the anterior dura provided easy access to the lesion for resection without any spinal cord retraction. Multiple intraoperative samples were sent to pathology for tissue diagnosis. The dura was closed with sutures and an overlay of fibrin sealant with collagen matrix sponge. The fusion procedures were performed using a standard occipital cervical plate and screws technique with contoured titanium rods. CONCLUSIONS The posterior cervical transdural approach is a safe alternative procedure for mucoid and fibrous soft or semi-soft retro-odontoid pseudotumor mass removal. Preoperative CT scan can evaluate tissue characteristics and distinguish between a soft or ossified mass in front of the spinal cord. Local anatomical conditions facilitate less bleeding and adhesions, together with less spinal cord traction, in the intradural space. Cranio-cervical and suboccipital stabilization can be easily and safely performed with this exposure.
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Affiliation(s)
- M Schomacher
- Vivantes Neurochirurgie, Klinikum Neukoelln, Rudower Str. 48, 12351, Berlin, Germany
| | - F Jiang
- Division of Orthopaedic Surgery, Department of Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.,Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - M Alrjoub
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada
| | - C D Witiw
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - P Diamandis
- Department of Pathology, Laboratory Medicine Program, University Health Network, University of Toronto, 200 Elizabeth Street, Toronto, ON, M5G2C4, Canada
| | - M G Fehlings
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada. .,Department of Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.
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210
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De la Garza Ramos R, Nouri A, Nakhla J, Echt M, Gelfand Y, Patel SK, Nasser R, Cheng JS, Yassari R, Fehlings MG. Predictors of Return to Normal Neurological Function After Surgery for Moderate and Severe Degenerative Cervical Myelopathy: An Analysis of A Global AOSpine Cohort of Patients. Neurosurgery 2020; 85:E917-E923. [PMID: 31144725 DOI: 10.1093/neuros/nyz178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/27/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Multiple studies have established the safety and efficacy of surgical intervention for degenerative cervical myelopathy (DCM). Although the main goal of surgery is symptom stabilization, a subset of patients achieves remarkable improvements. OBJECTIVE To identify predictors of return to normal neurological function after surgery for moderate or severe DCM. METHODS This is an analysis of 2 prospective multicenter studies (the AOSpine CSM-North America and CSM-International studies) conducted between 2005 and 2011. For patients with complete preoperative magnetic resonance imaging (MRI) and 2-yr follow-up, characteristics were compared between those who achieved a modified Japanese Orthopaedic Association (mJOA) score of 18 at 2 yr (no signs of myelopathy) vs controls. Only patients with baseline mJOA ≤ 14 (moderate and severe myelopathy) were included to minimize ceiling effects. RESULTS A total of 51 patients (20.3%) out of 251 with moderate or severe baseline myelopathy achieved an mJOA score of 18 at 2 yr. On stepwise multiple logistic regression analysis, T1-weighted (T1W1)-hypointensity (odds ratio [OR] 0.10; 95% confidence interval [CI], 0.01-0.79; P = .03) and longer walking time on the 30-m walking test (OR 0.95; 95% CI, 0.92-0.99; P = .03) were independent predictors of outcome, with an area under the curve of 0.71 for the model. CONCLUSION In this study, T1W-hypointensity on MRI and longer walking time were found to predict a less likelihood of achieving return to normal neurological function after surgery for moderate or severe DCM. These findings may provide useful information for patient counseling and perioperative expectations.
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Affiliation(s)
- Rafael De la Garza Ramos
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Aria Nouri
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Murray Echt
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Yaroslav Gelfand
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Smruti K Patel
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rani Nasser
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Joseph S Cheng
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Reza Yassari
- Department of Neurological Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Michael G Fehlings
- Division of Neurosurgery and Spinal Program, University of Toronto, Toronto, Canada
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211
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Badhiwala JH, Witiw CD, Nassiri F, Akbar MA, Mansouri A, Wilson JR, Fehlings MG. Efficacy and Safety of Surgery for Mild Degenerative Cervical Myelopathy: Results of the AOSpine North America and International Prospective Multicenter Studies. Neurosurgery 2020; 84:890-897. [PMID: 29684181 PMCID: PMC6425462 DOI: 10.1093/neuros/nyy133] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 03/27/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is controversy over the optimal treatment strategy for patients with mild degenerative cervical myelopathy (DCM). OBJECTIVE To evaluate the degree of impairment in baseline quality of life as compared to population norms, as well as functional, disability, and quality of life outcomes following surgery in a prospective cohort of mild DCM patients undergoing surgical decompression. METHODS We identified patients with mild DCM (modified Japanese Orthopaedic Association [mJOA] 15 to 17) enrolled in the prospective, multicenter AOSpine CSM-NA or CSM-I trials. Baseline quality of life Short Form-36 version 2 (SF-36v2) was compared to population norms by the standardized mean difference (SMD). Outcomes, including functional status (mJOA, Nurick grade), disability (NDI [Neck Disability Index]), and quality of life (SF-36v2), were evaluated at baseline and 6 mo, 1 yr, and 2 yr after surgery. Postoperative complications within 30 d of surgery were monitored. RESULTS One hundred ninety-three patients met eligibility criteria. Mean age was 52.4 yr. There were 67 females (34.7%). Patients had significant impairment in all domains of the SF-36v2 compared to population norms, greatest for Social Functioning (SMD –2.33), Physical Functioning (SMD –2.31), and Mental Health (SMD –2.30). A significant improvement in mean score from baseline to 2-yr follow-up was observed for all major outcome measures, including mJOA (0.87, P < .01), Nurick grade (–1.13, P < .01), NDI (–12.97, P < .01), and SF-36v2 Physical Component Summary (PCS) (5.75, P < .01) and Mental Component Summary (MCS) (6.93, P < .01). The rate of complication was low. CONCLUSION Mild DCM is associated with significant impairment in quality of life. Surgery results in significant gains in functional status, level of disability, and quality of life.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad A Akbar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Tetreault LA, Zhu MP, Wilson JR, Karadimas SK, Fehlings MG. The Impact of Riluzole on Neurobehavioral Outcomes in Preclinical Models of Traumatic and Nontraumatic Spinal Cord Injury: Results From a Systematic Review of the Literature. Global Spine J 2020; 10:216-229. [PMID: 32206521 PMCID: PMC7076594 DOI: 10.1177/2192568219835516] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To evaluate the impact of riluzole on neurobehavioral outcomes in preclinical models of nontraumatic and traumatic spinal cord injury (SCI). METHODS An extensive search of the literature was conducted in Medline, EMBASE, and Medline in Process. Studies were included if they evaluated the impact of riluzole on neurobehavioral outcomes in preclinical models of nontraumatic and traumatic SCI. Extensive data were extracted from relevant studies, including sample characteristics, injury model, outcomes assessed, timing of evaluation, and main results. The SYRCLE checklist was used to assess various sources of bias. RESULTS The search yielded a total of 3180 unique citations. A total of 16 studies were deemed relevant and were summarized in this review. Sample sizes ranged from 14 to 90, and injury models included traumatic SCI (n = 9), degenerative cervical myelopathy (n = 2), and spinal cord-ischemia (n = 5). The most commonly assessed outcome measures were BBB (Basso, Beattie, Besnahan) locomotor score and von Frey filament testing. In general, rats treated with riluzole exhibited significantly higher BBB locomotor scores than controls. Furthermore, riluzole significantly increased withdrawal thresholds to innocuous stimuli and tail flick latency following application of radiant heat stimuli. Finally, rats treated with riluzole achieved superior results on many components of gait assessment. CONCLUSION In preclinical models of traumatic and nontraumatic SCI, riluzole significantly improves locomotor scores, gait function, and neuropathic pain. This review provides the background information necessary to interpret the results of clinical trials on the impact of riluzole in traumatic and nontraumatic SCI.
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Affiliation(s)
- Lindsay A. Tetreault
- Toronto Western Hospital, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,University College Cork, Cork, Ireland
| | - Mary P. Zhu
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Spyridon K. Karadimas
- Toronto Western Hospital, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Toronto Western Hospital, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario M5T2S8, Canada.
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213
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Affiliation(s)
- Ali Moghaddamjou
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Neurosurgery, Spinal Program, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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214
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Kalsi-Ryan S, Rienmueller AC, Riehm L, Chan C, Jin D, Martin AR, Badhiwala JH, Akbar MA, Massicotte EM, Fehlings MG. Quantitative Assessment of Gait Characteristics in Degenerative Cervical Myelopathy: A Prospective Clinical Study. J Clin Med 2020; 9:jcm9030752. [PMID: 32164395 PMCID: PMC7141273 DOI: 10.3390/jcm9030752] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/18/2022] Open
Abstract
It is challenging to discriminate the early presentation of Degenerative Cervical Myelopathy (DCM) as well as sensitively and accurately distinguishing between mild, moderate, and severe levels of impairment. As gait dysfunction is one of the cardinal symptoms of DCM, we hypothesized that spatiotemporal gait parameters, including the enhanced gait variability index (eGVI), could be used to sensitively discriminate between different severities of DCM. A total of 153 patients recently diagnosed with DCM were recruited and stratified on the basis of DCM severity grades, as measured using the modified Japanese Orthopedic Association (mJOA) scale. Demographic information and neurological status were collected. Gait assessments were performed using an 8 m walkway. Spearman rank correlation was used to identify relationships between gait parameters and mJOA values as well as the mJOA lower extremity (LE) subscore. Kruskal–Wallis H test was performed to evaluate differences between severity groups, as defined by mJOA classification. A significant and relatively strong correlation was found between the mJOA score and eGVI, as well as between the LE subscore of the mJOA and eGVI. Significant differences in the eGVI (X2(2, N = 153) = 55.04, p < 0.0001, ε2 = 0.36) were found between all groups of DCM severity, with a significant increase in the eGVI as DCM progressed from mild to moderate. The eGVI was the most discriminative gait parameter, which facilitated objective differentiation between varying severities of DCM. Quantitative gait assessments show promise as an accurate and objective tool to diagnose and classify DCM, as well as to potentially evaluate the impact of therapeutic interventions.
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Affiliation(s)
- Sukhvinder Kalsi-Ryan
- KITE-UHN, Toronto, ON M5G 2A2, Canada;
- Department of Physical Therapy, University of Toronto, Toronto, ON M5G 1V7, Canada
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Anna C. Rienmueller
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
- Department of Orthopedic Surgery and Traumatology, Medical University Vienna, 1090 Vienna, Austria
| | - Lauren Riehm
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
| | - Colin Chan
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
| | - Daniel Jin
- Department of Kinesiology, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
| | - Allan R. Martin
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Jetan H. Badhiwala
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Muhammad A. Akbar
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Eric M. Massicotte
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
| | - Michael G. Fehlings
- Spine Program; Krembil Brain Institute; University Health Network, Toronto, ON M5T 2S8, Canada; (A.C.R.); (L.R.); (C.C.); (A.R.M.); (J.H.B.); (M.A.A.); (E.M.M.)
- Department of Surgery and Spine Program, University of Toronto, Toronto, ON M5T 1P5, Canada
- Correspondence:
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Trigiani LJ, Lacalle-Aurioles M, Bourourou M, Li L, Greenhalgh AD, Zarruk JG, David S, Fehlings MG, Hamel E. Benefits of physical exercise on cognition and glial white matter pathology in a mouse model of vascular cognitive impairment and dementia. Glia 2020; 68:1925-1940. [PMID: 32154952 DOI: 10.1002/glia.23815] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/06/2020] [Accepted: 02/24/2020] [Indexed: 12/16/2022]
Abstract
White matter (WM) pathology is a clinically predictive feature of vascular cognitive impairment and dementia (VCID). Mice overexpressing transforming growth factor-β1 (TGF) with an underlying cerebrovascular pathology when fed a high cholesterol diet (HCD) develop cognitive deficits (VCID mice) that we recently found could be prevented by physical exercise (EX). Here, we further investigated cognitive and WM pathology in VCID mice and examined the cellular substrates of the protective effects of moderate aerobic EX focusing on WM alterations. Six groups were studied: Wild-type (WT) and TGF mice (n = 20-24/group) fed standard lab chow or a 2% HCD, with two HCD-fed groups given concurrent access to running wheels. HCD had a significant negative effect in TGF mice that was prevented by EX on working and object recognition memory, the latter also altered in WT HCD mice. Whisker-evoked increases in cerebral blood flow (CBF) were reduced in HCD-fed mice, deficits that were countered by EX, and baseline WM CBF was similarly affected. VCID mice displayed WM functional deficits characterized by lower compound action potential amplitude not found in EX groups. Moreover, there was an increased number of collapsing capillaries, galectin-3-expressing microglial cells, as well as a reduced number of oligodendrocytes in the WM of VCID mice; all of which were prevented by EX. Our findings indicate that a compromised cerebral circulation precedes reduced WM vascularization, enhanced WM inflammation and impaired oligodendrogenesis that all likely account for the increased susceptibility to memory impairments in VCID mice, which can be prevented by EX. MAIN POINTS: A compromised cerebral circulation increases susceptibility to anatomical and functional white matter changes that develop alongside cognitive deficits when challenged with a high cholesterol diet; preventable by a translational regimen of exercise.
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Affiliation(s)
- Lianne J Trigiani
- Laboratory of Cerebrovascular Research, Montreal Neurological Institute, McGill University, Montréal, Quebec, Canada
| | - María Lacalle-Aurioles
- Laboratory of Cerebrovascular Research, Montreal Neurological Institute, McGill University, Montréal, Quebec, Canada
| | - Miled Bourourou
- Laboratory of Cerebrovascular Research, Montreal Neurological Institute, McGill University, Montréal, Quebec, Canada
| | - Lijun Li
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Andrew D Greenhalgh
- Center for Research in Neuroscience, The Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Juan G Zarruk
- Center for Research in Neuroscience, The Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Samuel David
- Center for Research in Neuroscience, The Research Institute of the McGill University Health Center, Montreal, Quebec, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Edith Hamel
- Laboratory of Cerebrovascular Research, Montreal Neurological Institute, McGill University, Montréal, Quebec, Canada
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216
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Altamentova S, Rumajogee P, Hong J, Beldick SR, Park SJ, Yee A, Fehlings MG. Methylprednisolone Reduces Persistent Post-ischemic Inflammation in a Rat Hypoxia-Ischemia Model of Perinatal Stroke. Transl Stroke Res 2020; 11:1117-1136. [PMID: 32140998 DOI: 10.1007/s12975-020-00792-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/12/2020] [Accepted: 02/19/2020] [Indexed: 12/21/2022]
Abstract
In perinatal stroke, the initial injury results in a chronic inflammatory response caused by the release of proinflammatory cytokines, gliosis and microglia activation. This chronic and ongoing inflammatory response exacerbates the brain injury, often resulting in encephalopathy and cerebral palsy (CP). Using a neonatal rat model of hypoxia-ischemia (HI) at postnatal day (P)7, we demonstrated that chronic inflammation is persistent and continues into the tertiary phase of perinatal stroke and can be attenuated by the administration of methylprednisolone sodium-succinate (MPSS, 30 mg/kg), a US Food and Drug Administration (FDA) approved anti-inflammatory agent. The inflammatory response was assessed by real-time quantitative PCR and ELISA for markers of inflammation (CCL3, CCL5, IL18 and TNFα). Structural changes were evaluated by histology (LFB/H&E), while cellular changes were assessed by Iba-1, ED1, GFAP, NeuN, Olig2 and CC1 immunostaining. Functional deficits were assessed with the Cylinder test and Ladder Rung Walking test. MPSS was injected 14 days after HI insult to attenuate chronic inflammation. In neonatal conditions such as CP, P21 is a clinically relevant time-point in rodents, corresponding developmentally to a 2-year-old human. Administration of MPSS resulted in reduced structural damage (corpus callosum, cortex, hippocampus, striatum), gliosis and reactive microglia and partial restoration of the oligodendrocyte population. Furthermore, significant behavioural recovery was observed. In conclusion, we demonstrated that administration of MPSS during the tertiary phase of perinatal stroke results in attenuation of the chronic inflammatory response, leading to pathophysiological and functional recovery. This work validates the high clinical impact of MPSS to treat neonatal conditions linked to chronic inflammation.
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Affiliation(s)
- Svetlana Altamentova
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Prakasham Rumajogee
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - James Hong
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Stephanie R Beldick
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Sei Joon Park
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Albert Yee
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada. .,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada. .,Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada. .,Division of Neurosurgery, Toronto Western Hospital, University Health Network, 399 Bathurst St. Suite 4WW-449, Toronto, Ontario, M5T 2S8, Canada.
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217
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Charalampidis A, Fehlings MG. Commentary: Reliability of the New AOSpine Classification System for Upper Cervical Traumatic Injuries. Neurosurgery 2020; 86:E271-E272. [PMID: 31814029 DOI: 10.1093/neuros/nyz537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anastasios Charalampidis
- Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Michael G Fehlings
- Division of Neurosurgery, Spinal Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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218
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Bond MR, Versteeg AL, Sahgal A, Rhines LD, Sciubba DM, Schuster JM, Weber MH, Fehlings MG, Lazary A, Clarke MJ, Boriani S, Bettegowda C, Arnold PM, Gokaslan ZL, Fisher CG. Surgical or Radiation Therapy for the Treatment of Cervical Spine Metastases: Results From the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) Cohort. Global Spine J 2020; 10:21-29. [PMID: 32002346 PMCID: PMC6963359 DOI: 10.1177/2192568219839407] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY DESIGN Ambispective cohort study design. OBJECTIVES Cervical spine metastases have distinct clinical considerations. The aim of this study was to determine the impact of surgical intervention (± radiotherapy) or radiotherapy alone on health-related quality of life (HRQOL) outcomes in patients treated for cervical metastatic spine tumours. METHODS Patients treated with surgery and/or radiotherapy for cervical spine metastases were identified from the Epidemiology, Process, and Outcomes of Spine Oncology (EPOSO) international multicentre prospective observational study. Demographic, diagnostic, treatment, and HRQOL (numerical rating scale [NRS] pain, EQ-5D (3L), SF-36v2, and SOSGOQ) measures were prospectively collected at baseline, 6 weeks, 3 months, and 6 months postintervention. RESULTS Fifty-five patients treated for cervical metastases were identified: 38 underwent surgery ± radiation and 17 received radiation alone. Surgically treated patients had higher mean spinal instability neoplastic scores compared with the radiation-alone group (13.0 vs 8.0, P < .001) and higher NRS pain scores and lower HRQOL scores compared to the radiation alone group (P < .05). From baseline to 6 months posttreatment, surgically treated patients demonstrated statistically significant improvements in NRS pain, EQ-5D (5L), and SOSGOQ2.0 scores compared with nonsignificant improvements in the radiotherapy alone group. CONCLUSIONS Surgically treated cervical metastases patients presented with higher levels of instability, worse baseline pain and HRQOL scores compared with patients who underwent radiotherapy alone. Significant improvements in pain and HRQOL were noted for those patients who received surgical intervention. Limited or no improvements were found in those treated with radiotherapy alone.
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Affiliation(s)
- Michael R. Bond
- University of British Columbia, Vancouver, British Columbia, Canada
- Michael R. Bond, Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, 818 West 10th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada.
| | | | - Arjun Sahgal
- Sunnybrook Odette Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Michael H. Weber
- McGill University and Montreal General Hospital, Montreal, Quebec, Canada
| | - Michael G. Fehlings
- University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - Aron Lazary
- National Center for Spinal Disorders and Buda Health Center, Budapest, Hungary
| | | | | | | | - Paul M. Arnold
- The University of Kansas Hospital, Kansas City, Kansas, USA
| | - Ziya L. Gokaslan
- The Warren Alpert Medical School of Brown University and Rhode Island Hospital and The Miriam Hospital, Providence, RI, USA
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219
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Badhiwala JH, Ellenbogen Y, Khan O, Nouri A, Jiang F, Wilson JR, Jaja B, Witiw CD, Nassiri F, Fehlings MG, Wilson JR. Comparison of the Inpatient Complications and Health Care Costs of Anterior versus Posterior Cervical Decompression and Fusion in Patients with Multilevel Degenerative Cervical Myelopathy: A Retrospective Propensity Score–Matched Analysis. World Neurosurg 2020; 134:e112-e119. [DOI: 10.1016/j.wneu.2019.09.132] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
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220
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Srikandarajah N, Noble A, Clark S, Wilby M, Freeman BJC, Fehlings MG, Williamson PR, Marson T. Cauda Equina Syndrome Core Outcome Set (CESCOS): An international patient and healthcare professional consensus for research studies. PLoS One 2020; 15:e0225907. [PMID: 31923259 PMCID: PMC6953762 DOI: 10.1371/journal.pone.0225907] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 11/14/2019] [Indexed: 01/17/2023] Open
Abstract
Background Cauda Equina Syndrome (CES) is an emergency condition that requires acute intervention and can lead to permanent neurological deficit in working age adults. A Core Outcome Set (COS) is the minimum set of outcomes that should be reported by a research study within a specific disease area. There is significant heterogeneity in outcome reporting for CES, which does not allow data synthesis between studies. The hypothesis is that a COS for CES can be developed for future research studies using patients and healthcare professionals (HCPs) as key stakeholders. Methods and findings Qualitative semi-structured interviews with CES patients were audio-recorded, transcribed and analysed using NVivo to identify the outcomes of importance. These were combined with the outcomes obtained from a published systematic literature review of CES patients. The outcomes were grouped into a list of 37, for rating through two rounds of an international Delphi survey according to pre-set criteria. The Delphi survey had an overall response rate of 63% and included 172 participants (104 patients, 68 HCPs) from 14 countries who completed both rounds. Thirteen outcomes reached consensus at the end of the Delphi survey and there was no attrition bias detected. The results were discussed at an international consensus meeting attended by 34 key stakeholders (16 patients and 18 HCPs) from 8 countries. A further three outcomes were agreed to be included. There was no selection bias detected at the consensus meeting. There are 16 outcomes in total in the CESCOS. Discussion This is the first study in the literature that has determined the core outcomes in CES using a transparent international consensus process involving healthcare professionals and CES patients as key stakeholders. This COS is recommended as the most important outcomes to be reported in any research study investigating CES outcomes and will allow evidence synthesis in CES.
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Affiliation(s)
- Nisaharan Srikandarajah
- Institute of Translational Medicine, University of Liverpool, Liverpool, Merseyside, United Kingdom
- * E-mail:
| | - Adam Noble
- Department of Health Services Research, Institute of Population Health Sciences, University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - Simon Clark
- Department of Spinal Surgery, The Walton Centre NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Martin Wilby
- Department of Spinal Surgery, The Walton Centre NHS Foundation Trust, Liverpool, Merseyside, United Kingdom
| | - Brian J. C. Freeman
- Department of Spinal Surgery, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | - Michael G. Fehlings
- Division of Neurosurgery and Spine Program, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Paula R. Williamson
- MRC North West Hub for Trials Methodology Research, Institute of Translational Medicine, University of Liverpool, Liverpool, Merseyside, United Kingdom
| | - Tony Marson
- Institute of Translational Medicine, University of Liverpool, Liverpool, Merseyside, United Kingdom
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221
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Abstract
STUDY DESIGN Narrative review. OBJECTIVE To summarize relevant studies regarding the utilization of intraoperative neurophysiological monitoring (IONM) techniques in spine surgery implemented in recent years. METHODS A literature search of the Medline database was performed. Relevant studies from all evidence levels have been included. Titles, abstracts, and reference lists of key articles were included. RESULTS Multimodal intraoperative neurophysiological monitoring (MIONM) has the advantage of compensating for the limitations of each individual technique and seems to be effective and accurate for detecting perioperative neurological injury during spine surgery. CONCLUSION Although there are no prospective studies validating the efficacy of IONM, there is a growing body of evidence supporting its use during spinal surgery. However, the lack of validated protocols to manage intraoperative alerts highlights a critical knowledge gap. Future investigation should focus on developing treatment methodology, validating practice protocols, and synthesizing clinical guidelines.
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Affiliation(s)
- Anastasios Charalampidis
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,Department of Clinical Sciences, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden,Department of Reconstructive Orthopaedics, Karolinska University Hospital, Stockholm, Sweden
| | - Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst St, Toronto, Ontario M5T2S8, Canada.
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222
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Abstract
STUDY DESIGN Narrative review. OBJECTIVE There is a strong biological rationale to perform early decompression after traumatic spinal cord injury (SCI). With an enlarging clinical evidence base, most spine surgeons internationally now favor early decompression for the majority of SCI patients; however, a number of pertinent questions remain surrounding this therapy. METHODS A narrative review evaluating the status of early surgery for SCI. In particular, we addressed the following questions: (1) Which patients stand to benefit most from early surgery? 2) What is the most appropriate time threshold defining early surgery? RESULTS Although heterogeneity exists, the evidence generally seems to support early surgery. While the best evidence exists for cervical SCI, there is insufficient data to support a differential effect for early surgery depending on neurological level or injury severity. When comparing thresholds to define early versus late surgery-including a later threshold (48-72 hours), an earlier threshold (24 hours), and an ultra-early threshold (8-12 hours)-the 2 earlier time points seem to be associated with the greatest potential for improved outcomes. However, existing prehospital and hospital logistics pose barriers to early surgery in a significant proportion of patients. An overview of recommendations from the recent AOSpine guidelines is provided. CONCLUSION In spite of increasing acceptance of early surgery post SCI, further research is needed to (1) identify subgroups of patients who stand to derive particular benefit-in particular to develop more evidence-based approaches for central cord syndrome and (2) investigate the efficacy and feasibility of ultra-early surgery targeting more aggressive timelines.
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Affiliation(s)
- Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,Jefferson R. Wilson, Division of Neurosurgery, St Michael’s Hospital, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada.
| | | | | | - Brian K. Kwon
- University of British Columbia, Vancouver, British Columbia, Canada
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223
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Abstract
STUDY DESIGN Review article. OBJECTIVES A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery. METHODS A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review. RESULTS Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature. CONCLUSION Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.
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Affiliation(s)
- Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T2S8, Canada.
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224
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Abstract
STUDY DESIGN Narrative review with commentary. OBJECTIVE Present healthcare reform focuses on cost-optimization and quality improvement. Spine surgery has garnered particular attention; owing to its costly nature. Ambulatory Surgical Centers (ASC) present a potential avenue for expenditure reduction. While the economic advantage of ASCs is being defined, cost saving should not come at the expense of quality or safety. METHODS This narrative review focuses on current definitions, regulations, and recent medical literature pertinent to spinal surgery in the ASC setting. RESULTS The past decade witnessed a substantial rise in the proportion of certain spinal surgeries performed at ASCs. This setting is attractive from the payer perspective as remuneration rates are generally less than for equivalent hospital-based procedures. Opportunity for physician ownership and increased surgeon productivity afforded by more specialized centers make ASCs attractive from the provider perspective as well. These factors serve as extrinsic motivators which may optimize and improve quality of surgical care. Much data supports the safety of spine surgery in the ASC setting. However, health care providers and policy makers must recognize that current regulations regarding safety and quality are less than comprehensive and the data is predominately from selected case-series or comparative cohorts with inherent biases, along with ambiguities in the definition of "outpatient." CONCLUSIONS ASCs hold promise for providing safe and efficient surgical management of spinal conditions; however, as more procedures shift from the hospital to the ASC rigorous quality and safety data collection is needed to define patient appropriateness and track variability in quality-related outcomes.
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Affiliation(s)
| | | | | | - Vincent C. Traynelis
- Rush University Medical Center, Chicago, IL, USA,Vincent C. Traynelis, Department of Neurological Surgery, Rush University Medical Center, 1725 West Harrison Street, Chicago, IL 60612, USA.
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225
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Mikhail C, Pennington Z, Arnold PM, Brodke DS, Chapman JR, Chutkan N, Daubs MD, DeVine JG, Fehlings MG, Gelb DE, Ghobrial GM, Harrop JS, Hoelscher C, Jiang F, Knightly JJ, Kwon BK, Mroz TE, Nassr A, Riew KD, Sekhon LH, Smith JS, Traynelis VC, Wang JC, Weber MH, Wilson JR, Witiw CD, Sciubba DM, Cho SK. Minimizing Blood Loss in Spine Surgery. Global Spine J 2020; 10:71S-83S. [PMID: 31934525 PMCID: PMC6947684 DOI: 10.1177/2192568219868475] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
STUDY DESIGN Broad narrative review. OBJECTIVE To review and summarize the current literature on guidelines, outcomes, techniques and indications surrounding multiple modalities of minimizing blood loss in spine surgery. METHODS A thorough review of peer-reviewed literature was performed on the guidelines, outcomes, techniques, and indications for multiple modalities of minimizing blood loss in spine surgery. RESULTS There is a large body of literature that provides a consensus on guidelines regarding the appropriate timing of discontinuation of anticoagulation, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and herbal supplements prior to surgery. Additionally, there is a more heterogenous discussion the utility of preoperative autologous blood donation facilitated by erythropoietin and iron supplementation for healthy patients slated for procedures with high anticipated blood loss and for whom allogeneic transfusion is likely. Intraoperative maneuvers available to minimize blood loss include positioning and maintaining normothermia. Tranexamic acid (TXA), bipolar sealer electrocautery, and topical hemostatic agents, and hypotensive anesthesia (mean arterial pressure (MAP) <65 mm Hg) should be strongly considered in cases with larger exposures and higher anticipated blood loss. There is strong level 1 evidence for the use of TXA in spine surgery as it reduces the overall blood loss and transfusion requirements. CONCLUSION As the volume and complexity of spinal procedures rise, intraoperative blood loss management has become a pivotal topic of research within the field. There are many tools for minimizing blood loss in patients undergoing spine surgery. The current literature supports combining techniques to use a cost- effective multimodal approach to minimize blood loss in the perioperative period.
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Affiliation(s)
| | | | - Paul M. Arnold
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Norman Chutkan
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - John G. DeVine
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Daniel E. Gelb
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Fan Jiang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Brian K. Kwon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Thomas E. Mroz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmad Nassr
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - K. Daniel Riew
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lali H. Sekhon
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | | | | | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, New York, NY, USA,Samuel K. Cho, Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, 5 East 98th Street, New York, NY 10029, USA.
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226
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Affiliation(s)
- Kazuya Yokota
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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227
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Khan O, Badhiwala JH, Wilson JRF, Jiang F, Martin AR, Fehlings MG. Predictive Modeling of Outcomes After Traumatic and Nontraumatic Spinal Cord Injury Using Machine Learning: Review of Current Progress and Future Directions. Neurospine 2019; 16:678-685. [PMID: 31905456 PMCID: PMC6945005 DOI: 10.14245/ns.1938390.195] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 12/15/2019] [Indexed: 12/17/2022] Open
Abstract
Machine learning represents a promising frontier in epidemiological research on spine surgery. It consists of a series of algorithms that determines relationships between data. Machine learning maintains numerous advantages over conventional regression techniques, such as a reduced requirement for a priori knowledge on predictors and better ability to manage large datasets. Current studies have made extensive strides in employing machine learning to a greater capacity in spinal cord injury (SCI). Analyses using machine learning algorithms have been done on both traumatic SCI and nontraumatic SCI, the latter of which typically represents degenerative spine disease resulting in spinal cord compression, such as degenerative cervical myelopathy. This article is a literature review of current studies published in traumatic and nontraumatic SCI that employ machine learning for the prediction of a host of outcomes. The studies described utilize machine learning in a variety of capacities, including imaging analysis and prediction in large epidemiological data sets. We discuss the performance of these machine learning-based clinical prognostic models relative to conventional statistical prediction models. Finally, we detail the future steps needed for machine learning to become a more common modality for statistical analysis in SCI.
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Affiliation(s)
- Omar Khan
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jetan H Badhiwala
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Jamie R F Wilson
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Fan Jiang
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Allan R Martin
- Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Michael G Fehlings
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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228
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Koziarz A, Sne N, Kegel F, Nath S, Badhiwala JH, Nassiri F, Mansouri A, Yang K, Zhou Q, Rice T, Faidi S, Passos E, Healey A, Banfield L, Mensour M, Kirkpatrick AW, Nassar A, Fehlings MG, Hawryluk GWJ, Almenawer SA. Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:896-905. [PMID: 31739316 DOI: 10.7326/m19-0812] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure. PURPOSE To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults. DATA SOURCES 13 databases from inception through May 2019, reference lists, and meeting proceedings. STUDY SELECTION Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard. DATA EXTRACTION 3 reviewers independently abstracted data and performed quality assessment. DATA SYNTHESIS Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm. LIMITATION Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes. CONCLUSION Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42017055485).
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Affiliation(s)
- Alex Koziarz
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Niv Sne
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Fraser Kegel
- McGill University, Montreal, Quebec, Canada (F.K.)
| | - Siddharth Nath
- School of Medicine, McMaster University, Hamilton, Ontario, Canada (S.N.)
| | - Jetan H Badhiwala
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Farshad Nassiri
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Alireza Mansouri
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Kaiyun Yang
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Qi Zhou
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Timothy Rice
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Samir Faidi
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Edward Passos
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Andrew Healey
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Laura Banfield
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Mark Mensour
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada (M.M.)
| | | | | | - Michael G Fehlings
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | | | - Saleh A Almenawer
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
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Patel K, Evans H, Sommaruga S, Vayssiere P, Qureshi T, Kolb L, Fehlings MG, Cheng JS, Tessitore E, Schaller K, Nouri A. Characteristics and management of pain in patients with Klippel-Feil syndrome: analysis of a global patient-reported registry. J Neurosurg Spine 2019; 32:1-6. [PMID: 31835254 DOI: 10.3171/2019.9.spine19820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 09/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Klippel-Feil syndrome (KFS) is characterized by congenital fusion of the cervical vertebrae. Due to its rarity, minimal research has been done to assess the quality and management of pain associated with this disorder. Using a large global database, the authors report a detailed analysis of the type, location, and treatment of pain in patients with KFS. METHODS Data were obtained from the Coordination of Rare Diseases at Stanford registry and Klippel-Feil Syndrome Freedom registry. The cervical fusions were categorized into Samartzis type I, II, or III. The independent-sample t-test, Wilcoxon rank-sum test, and Friedman test were conducted, with significance set at p < 0.05. RESULTS Seventy-five patients (60 female, 14 male, and 1 unknown) were identified and classified as having the following types of Samartzis fusion: type I, n = 21 (28%); type II, n = 15 (20%); type III, n = 39 (52%). Seventy participants (93.3%) experienced pain associated with their KFS. The median age of patients at pain onset was 16.0 years (IQR 6.75-24.0 years), and the median age when pain worsened was 28.0 years (IQR 15.25-41.5 years). Muscle, joint, and nerve pain was primarily located in the shoulders/upper back (76%), neck (72%), and back of head (50.7%) and was characterized as tightness (73%), dull/aching (67%), and tingling/pins and needles (49%). Type III fusions were significantly associated with greater nerve pain (p = 0.02), headache/migraine pain (p = 0.02), and joint pain (p = 0.03) compared to other types of fusion. Patients with cervical fusions in the middle region (C2-6) tended to report greater muscle, joint, and nerve pain (p = 0.06). Participants rated the effectiveness of oral over-the-counter medications as 3 of 5 (IQR 1-3), oral prescribed medications as 3 of 5 (IQR 2-4), injections as 2 of 5 (IQR 1-4), and surgery as 3 of 5 (IQR 1-4), with 0 indicating the least pain relief and 5 the most pain relief. Participants who pursued surgical treatment reported significantly more comorbidities (p = 0.02) and neurological symptoms (p = 0.01) than nonsurgically treated participants and were significantly older when pain worsened (p = 0.03), but there was no difference in levels of muscle, joint, or nerve pain (p = 0.32); headache/migraine pain (p = 0.35); total number of cervical fusions (p = 0.77); location of fusions; or age at pain onset (p = 0.16). CONCLUSIONS More than 90% of participants experienced pain. Participants with an increased number of overall cervical fusions or multilevel, contiguous fusions reported greater levels of muscle, joint, and nerve pain. Participants who pursued surgery had more comorbidities and neurological symptoms, such as balance and gait disturbances, but did not report more significant pain than nonsurgically treated participants.
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Affiliation(s)
- Kishan Patel
- 1Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Hardy Evans
- 2Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Samuel Sommaruga
- 3Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland; and
| | - Pia Vayssiere
- 3Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland; and
| | - Tariq Qureshi
- 1Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Luis Kolb
- 1Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael G Fehlings
- 4Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph S Cheng
- 2Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Enrico Tessitore
- 3Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland; and
| | - Karl Schaller
- 3Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland; and
| | - Aria Nouri
- 3Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland; and
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Freund P, Seif M, Weiskopf N, Friston K, Fehlings MG, Thompson AJ, Curt A. MRI in traumatic spinal cord injury: from clinical assessment to neuroimaging biomarkers. Lancet Neurol 2019; 18:1123-1135. [DOI: 10.1016/s1474-4422(19)30138-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 03/22/2019] [Accepted: 03/28/2019] [Indexed: 01/18/2023]
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Versteeg AL, Sahgal A, Kawahara N, Rhines LD, Sciubba DM, Weber MH, Lazary Á, Fehlings MG, Schuster JM, Clarke MJ, Arnold PM, Boriani S, Bettegowda C, Gokaslan ZL, Fisher CG. Patient satisfaction with treatment outcomes after surgery and/or radiotherapy for spinal metastases. Cancer 2019; 125:4269-4277. [PMID: 31490548 PMCID: PMC6900159 DOI: 10.1002/cncr.32465] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/18/2019] [Accepted: 07/26/2019] [Indexed: 11/17/2022]
Abstract
Background Patient satisfaction is infrequently investigated despite its importance in assessing efficacy and patient comprehension. The purpose of this study was to investigate patient satisfaction with treatment outcomes after surgery and/or radiotherapy for spinal metastases and to evaluate how health‐related quality of life (HRQOL) is related to patient satisfaction. Methods Patients with spinal metastases treated with surgery and/or radiotherapy were enrolled in a prospective, international, observational study. Demographic, histologic, treatment, and HRQOL data were collected. HRQOL was evaluated with the Numeric Rating Scale pain score, the 3‐level version of the EuroQol 5‐Dimension (EQ‐5D‐3L) instrument, and the Spine Oncology Study Group Outcomes Questionnaire (SOSGOQ2.0). Patient satisfaction was derived from the SOSGOQ2.0 at 6, 12, and 26 weeks after treatment. Patients were classified as satisfied, neutral, or dissatisfied. Results Twelve weeks after treatment, 183 of the surgically treated patients (84%) were satisfied, and only 11 (5%) were dissatisfied; in contrast, 101 of the patients treated with radiotherapy alone (77%) were satisfied, and only 7 (5%) were dissatisfied. Significant improvements in pain, physical function, mental health, social function, leg function, and EQ‐5D were associated with satisfaction after surgery. Satisfaction after radiotherapy was associated with significant improvements in pain, mental health, and overall SOSGOQ2.0 scores. Dissatisfaction after treatment was associated with lower baseline values for leg strength and lower social functioning scores for surgically treated patients and with lower social functioning scores and being single for patients treated with radiotherapy. Conclusions High levels of satisfaction with treatment outcomes are observed after surgery and/or radiotherapy for spinal metastases. Posttreatment satisfaction is associated with significant improvements in pain and different dimensions of HRQOL. High levels of satisfaction with treatment outcomes are observed after surgery and/or radiotherapy for spinal metastases. Posttreatment satisfaction is associated with significant improvements in pain and different dimensions of health‐related quality of life.
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Affiliation(s)
- Anne L Versteeg
- Department of Orthopedics, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Arjun Sahgal
- Department of Radiation Oncology, Sunnybrook Odette Cancer Centre and University of Toronto, Toronto, Ontario, Canada
| | - Norio Kawahara
- Department of Orthopedic Surgery, Kanazawa Medical University Hospital, Kanazawa, Japan
| | - Laurence D Rhines
- Department of Neurosurgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael H Weber
- Division of Surgery, McGill University and Montreal General Hospital, Montreal, Quebec, Canada
| | - Áron Lazary
- National Center for Spinal Disorders, Buda Health Center, Budapest, Hungary
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto and Toronto Western Hospital, Toronto, Ontario, Canada
| | - James M Schuster
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Paul M Arnold
- Department of Neurosurgery, University of Kansas Hospital, Kansas City, Kansas
| | - Stefano Boriani
- Institutes for Care and Scientific Research (IRCCS) Galeazzi Orthopedic Hospital, Milan, Italy
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ziya L Gokaslan
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Rhode Island Hospital, and Miriam Hospital, Providence, Rhode Island
| | - Charles G Fisher
- Division of Spine Surgery, Department of Orthopaedics, University of British Columbia and Vancouver General Hospital, Vancouver, British Columbia, Canada
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Karadimas SK, Satkunendrarajah K, Laliberte AM, Ringuette D, Weisspapir I, Li L, Gosgnach S, Fehlings MG. Sensory cortical control of movement. Nat Neurosci 2019; 23:75-84. [DOI: 10.1038/s41593-019-0536-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 10/08/2019] [Indexed: 01/07/2023]
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233
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Kumaria A, Bateman AH, Eames N, Fehlings MG, Goldstein C, Meyer B, Paquette SJ, Yee AJM. Advancing spinal fellowship training: an international multi-centre educational perspective. Eur Spine J 2019; 28:2437-2443. [PMID: 31407164 DOI: 10.1007/s00586-019-06098-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 03/19/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The purpose of this article is to review the importance of contemporary spine surgery fellowships and educational strategies to assist with fellowship design and delivery. METHODS Spine surgery fellowship includes trainees from orthopaedic and neurosurgical backgrounds and is increasingly indicated for individuals wishing to pursue spine surgery as a career, recognizing how spinal surgery evolved significantly in scope and complexity. We combine expert opinion with a review of the literature and international experience to expound spine fellowship training. RESULTS Contemporary learning techniques include boot camps at the start of fellowship which may reinforce previous clinical learning and help prepare fellows for their new clinical roles. There is good evidence that surgical specialty training boot camps improve clinical skills, knowledge and trainee confidence prior to embarking upon new clinical roles with increasing levels of responsibility. Furthermore, as simulation techniques and technologies take on an increasing role in medical and surgical training, we found evidence that trainees' operative skills and knowledge can improve with simulated operations, even if just carried out briefly. Finally, we found evidence to suggest a role for establishing competence-based objectives for training in specific operative and technical procedures. Competence-based objectives are helpful for trainees and trainers to highlight gaps in a trainee's skill set that may then be addressed during training. CONCLUSIONS Spinal fellowships may benefit from certain contemporary strategies that assist design and delivery of training in a safe environment. Interpersonal factors that promote healthy teamwork may contribute to an environment conducive to learning. These slides can be retrieved under Electronic Supplementary Material.
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Affiliation(s)
- Ashwin Kumaria
- Royal Derby Spinal Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
| | - Antony H Bateman
- Royal Derby Spinal Centre, Royal Derby Hospital, Uttoxeter Road, Derby, DE22 3NE, UK.
| | - Niall Eames
- Belfast Health and Social Care Trust, Royal Victoria Hospital, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto, ON, Canada
| | - Christina Goldstein
- Missouri Orthopaedic Institute, University of Missouri, 1100 Virginia Ave, Columbia, MO, 65212, USA
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | | | - Albert J M Yee
- Department of Surgery, University of Toronto, Toronto, Canada
- University of Toronto Spine Program, Toronto, Canada
- Marvin Tile Chair, Division Head of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Rm MG 371-B, Toronto, ON, M4N 3M5, Canada
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Jiang F, Jaja BNR, Kurpad SN, Badhiwala JH, Aarabi B, Grossman RG, Harrop JS, Guest JD, Schär RT, Shaffrey CI, Boakye M, Toups EG, Wilson JR, Fehlings MG. Acute Adverse Events After Spinal Cord Injury and Their Relationship to Long-term Neurologic and Functional Outcomes: Analysis From the North American Clinical Trials Network for Spinal Cord Injury. Crit Care Med 2019; 47:e854-e862. [PMID: 31389834 DOI: 10.1097/ccm.0000000000003937] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES There are few contemporary, prospective multicenter series on the spectrum of acute adverse events and their relationship to long-term outcomes after traumatic spinal cord injury. The goal of this study is to assess the prevalence of adverse events after traumatic spinal cord injury and to evaluate the effects on long-term clinical outcome. DESIGN Multicenter prospective registry. SETTING Consortium of 11 university-affiliated medical centers in the North American Clinical Trials Network. PATIENTS Eight-hundred one spinal cord injury patients enrolled by participating centers. INTERVENTIONS Appropriate spinal cord injury treatment at individual centers. MEASUREMENTS AND MAIN RESULTS A total of 2,303 adverse events were recorded for 502 patients (63%). Penalized maximum logistic regression models were fitted to estimate the likelihood of neurologic recovery (ASIA Impairment Scale improvement ≥ 1 grade point) and functional outcomes in subjects who developed adverse events at 6 months postinjury. After accounting for potential confounders, the group that developed adverse events showed less neurologic recovery (odds ratio, 0.55; 95% CI, 0.32-0.96) and was more likely to require assisted breathing (odds ratio, 6.55; 95% CI, 1.17-36.67); dependent ambulation (odds ratio, 7.38; 95% CI, 4.35-13.06) and have impaired bladder (odds ratio, 9.63; 95% CI, 5.19-17.87) or bowel function (odds ratio, 7.86; 95% CI, 4.31-14.32) measured using the Spinal Cord Independence Measure subscores. CONCLUSIONS Results from this contemporary series demonstrate that acute adverse events are common and are associated with worsened long-term outcomes after traumatic spinal cord injury.
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Affiliation(s)
- Fan Jiang
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
- Division of Orthopaedic Surgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Blessing N R Jaja
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Shekar N Kurpad
- Division of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Jetan H Badhiwala
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Bizhan Aarabi
- Division of Neurosurgery, Shock Trauma, University of Maryland, Baltimore, MD
| | | | - James S Harrop
- Division of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Jim D Guest
- Division of Neurosurgery, University of Miami, Miami, FL
| | - Ralph T Schär
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Chris I Shaffrey
- Division of Neurosurgery, University of Virginia, Chalottesville, VA
| | - Max Boakye
- Division of Neurosurgery, University of Louisville, Louisville, KY
| | | | - Jefferson R Wilson
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
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Badhiwala JH, Fehlings MG. Commentary: Recovery Kinetics: Comparison of Patients Undergoing Primary or Revision Procedures for Adult Cervical Deformity Using a Novel Area Under the Curve Methodology. Neurosurgery 2019; 85:E955-E956. [PMID: 30335181 DOI: 10.1093/neuros/nyy448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 08/17/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Tetreault LA, Zhu MP, Howard RM, Sorefan-Mangou F, Patel AA, Schroeder GD, Massicotte EM, Bhadiwala JH, Fehlings MG, Wilson JR. The discrepancy between functional outcome and self-reported health status after surgery for degenerative cervical myelopathy. Spine J 2019; 19:1809-1815. [PMID: 31278991 DOI: 10.1016/j.spinee.2019.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/25/2019] [Accepted: 06/30/2019] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Surgery for degenerative cervical myelopathy has shown not only to halt neurologic deterioration, but also to improve functional impairments. Despite these improvements, some patients may be dissatisfied with their outcomes. This study aims to (1) investigate discrepancies between postoperative clinical measures and self-reported health status, and (2) identify important predictors of such discrepancies. METHODS Four hundred and seventy-nine surgical patients were prospectively enrolled in the CSM-International study at 16 global sites. At 1-year post-op, patients rated their general health status compared with their immediate preoperative status (much better, somewhat better, the same, somewhat worse, much worse). Descriptive analyses were conducted to evaluate the agreement between achieving a clinically important improvement (MCID) in function (modified Japanese Orthopedic Association [mJOA] scale) and self-reported health status. Agreement was defined as achieving the MCID on the mJOA and reporting general health as somewhat better or much better, whereas disagreement was defined as achieving MCID on the mJOA and reporting general health as the same, somewhat worse or much worse. Logistic regression analysis was used to determine factors that influence agreement between self-report of health status and functional outcomes. RESULTS A total of 395 patients had complete follow-up data at 1-year and were included in this analysis. Based on patient self-reports, 56 (14.2%) were somewhat or much worse than a year ago, 80 (20.2%) patients were the same and 259 (65.6%) patients were somewhat or much better. Thirty percent of patients who reported being somewhat or much worse were found to achieve the MCID on the mJOA; 57.5% of patients who indicated their health status were the same as before surgery also exhibited clinically meaningful improvements in functional impairment. Based on multivariate analysis, there was an increased odds of observing an agreement between self-reports of health status and functional outcomes if the patient exhibited greater improvement in mJOA upper extremity motor function at 1-year (odds ratio [OR]: 1.41, 95% confidence interval [CI] 1.03-1.93, p=.033) and reduced odds of agreement with increased age (OR for every decade: 0.66, 95% CI 0.50-0.87, p=.0035) and increased bodily pain at 1-year (OR: 0.62, 95% CI 0.49-078, p<.0001). CONCLUSIONS There was a discrepancy between changes in mJOA and self-reports of health status in patients undergoing surgery for degenerative cervical myelopathy. Increased bodily pain at 1-year, smaller improvements in postoperative upper extremity score and increased age were associated with worsened or unchanged general health status, despite clinically significant improvements in overall postoperative function.
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Affiliation(s)
- Lindsay A Tetreault
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Canada M5T 2S8; Graduate Entry Medicine, University College Cork, College Rd, University College, Cork T12 K8AF Ireland
| | - Mary P Zhu
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, Canada M5W 1W8
| | - Rachel M Howard
- Graduate Entry Medicine, University College Cork, College Rd, University College, Cork T12 K8AF Ireland
| | - Fatimah Sorefan-Mangou
- Graduate Entry Medicine, University College Cork, College Rd, University College, Cork T12 K8AF Ireland
| | - Alpesh A Patel
- Department of Orthopedic Surgery, Feinberg School of Medicine, Northwestern University, 420 E Superior Street, Chicago, IL 60611, USA
| | - Gregory D Schroeder
- Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Eric M Massicotte
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Canada M5T 2S8
| | - Jetan H Bhadiwala
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Canada M5T 2S8
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, 399 Bathurst Street, Toronto, Canada M5T 2S8
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, St. Michael's Hospital, 30 Bond Street, Toronto, Canada M5W 1W8; Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, Canada M5B 1T8.
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Badhiwala JH, Karmur BS, Hachem LD, Wilson JRF, Jiang F, Jaja B, Nouri A, Witiw CD, Nassiri F, Fehlings MG, Wilson JR. The Effect of Older Age on the Perioperative Outcomes of Spinal Fusion Surgery in Patients With Lumbar Degenerative Disc Disease With Spondylolisthesis: A Propensity Score-Matched Analysis. Neurosurgery 2019; 87:672-678. [DOI: 10.1093/neuros/nyz444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/18/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Degenerative spondylolisthesis (DS) is often treated with lumbar spinal fusion (LSF). However, there is concern that the morbidity of LSF may be prohibitively high in older adults.
OBJECTIVE
To evaluate the impact of advanced age on the safety of LSF for DS.
METHODS
Patients who underwent LSF for DS were retrospectively identified from National Surgical Quality Improvement Program datasets for 2011 to 2015 using Current Procedural Terminology codes. Data on demographic characteristics, comorbidities, surgical factors, and 30-d morbidity and mortality were collected. Propensity score matching (nearest neighbor) was performed with age (<70 vs ≥70 yr) as the dependent variable and sex, type of fusion procedure, number of levels fused, diabetes, smoking, hypertension, and chronic steroid use as covariates. Outcomes were compared between age <70 and ≥70 groups.
RESULTS
The study cohort consisted of 2238 patients (n = 1119, age <70; n = 1119, age ≥70). The 2 age groups were balanced for key covariates including sex, race, diabetes, hypertension, CHF, smoking, chronic steroid use, type of fusion, and number of levels. Rates of all complications were similar between younger and older age groups, except urinary tract infection, which was more frequent among the ≥70 age group (OR 2.32, P = .009). Further, patients in the older age group were more likely to be discharged to a rehabilitation (OR 2.94, P < .001) or skilled care (OR 3.66, P < .001) facility, rather than directly home (OR 0.25, P < .001).
CONCLUSION
LSF may be performed safely in older adults with DS. Our results suggest older age alone should not exclude a patient from undergoing lumbar fusion for DS.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Brij S Karmur
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Laureen D Hachem
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jamie R F Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Fan Jiang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Blessing Jaja
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Aria Nouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
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Laufer I, Lo SS, Chang EL, Sheehan J, Guckenberger M, Sohn MJ, Ryu S, Foote M, Muacevic A, Soltys SG, Chao S, Myrehaug S, Gerszten PC, Lis E, Maralani P, Bilsky M, Fisher C, Rhines L, Verlaan JJ, Schiff D, Fehlings MG, Ma L, Chang S, Parulekar WR, Vogelbaum MA, Sahgal A. Population description and clinical response assessment for spinal metastases: part 2 of the SPIne response assessment in Neuro-Oncology (SPINO) group report. Neuro Oncol 2019; 20:1215-1224. [PMID: 29590465 DOI: 10.1093/neuonc/noy047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Approximately 40% of metastatic cancer patients will develop spinal metastases. The current report provides recommendations for standardization of metrics used for spinal oncology patient population description and outcome assessment beyond local control endpoints on behalf of the SPIne response assessment in Neuro-Oncology (SPINO) group. Methods The SPINO group survey was conducted in order to determine the preferences for utilization of clinician-based and patient-reported outcome measures for description of patients with spinal metastases. Subsequently, ClinicalTrials.gov registry was searched for spinal oncology clinical trials, and measures for patient description and outcome reporting were identified for each trial. These two searches were used to identify currently used descriptors and instruments. A literature search was performed focusing on the measures identified in the survey and clinical trial search in order to assess their validity in the metastatic spinal tumor patient population. References for this manuscript were identified through PubMed and Medline searches. Results Published literature, expert survey, and ongoing clinical trials were used to synthesize recommendations for instruments for reporting of spinal stability, epidural tumor extension, neurological and functional status, and symptom severity. Conclusions Accurate description of patient population and therapy effects requires a combination of clinician-based and patient-reported outcome measures. The current report provides international consensus recommendations for the systematic reporting of patient- and clinician-reported measures required to develop trials applicable to surgery for spinal metastases and postoperative spine stereotactic body radiotherapy (SBRT).
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Affiliation(s)
- Ilya Laufer
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Simon S Lo
- Department of Radiation Oncology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eric L Chang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Jason Sheehan
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | | | - Moon-Jun Sohn
- Department of Neurosurgery, Neuroscience & Radiosurgery Hybrid Research Center, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Samuel Ryu
- Department of Radiation Oncology, Stony Brook University, Stony Brook, New York, USA
| | - Matthew Foote
- Department of Radiation Oncology, University of Queensland, Princess Alexandra Hospital, Brisbane, Australia
| | - Alexander Muacevic
- Department of Neurosurgery, University of Munich Hospital, Munich, Germany
| | - Scott G Soltys
- Department of Radiation Oncology, Stanford University Medical Center, Stanford, California, USA
| | - Samuel Chao
- Department of Radiation Oncology, Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sten Myrehaug
- NCIC Canadian Cancer Trials Group, Kingston, Ontario, Canada
| | - Peter C Gerszten
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Pejman Maralani
- Department of Medical Imaging, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | - Mark Bilsky
- Department of Neurosurgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Charles Fisher
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurence Rhines
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jorrit-Jan Verlaan
- Department of Orthopedic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - David Schiff
- Division of Neuro-Oncology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Michael G Fehlings
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lijun Ma
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California, USA
| | - Susan Chang
- Department of Neurosurgery, University of California San Francisco, San Francisco, California, USA
| | | | - Michael A Vogelbaum
- Brain Tumor and Neuro Oncology Center and Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arjun Sahgal
- Department of Radiation Oncology, University of Toronto, Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
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239
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Wilson JRF, Badhiwala JH, Jiang F, Wilson JR, Kopjar B, Vaccaro AR, Fehlings MG. The Impact of Older Age on Functional Recovery and Quality of Life Outcomes after Surgical Decompression for Degenerative Cervical Myelopathy: Results from an Ambispective, Propensity-Matched Analysis from the CSM-NA and CSM-I International, Multi-Center Studies. J Clin Med 2019; 8:jcm8101708. [PMID: 31627303 PMCID: PMC6833063 DOI: 10.3390/jcm8101708] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 10/09/2019] [Accepted: 10/13/2019] [Indexed: 11/20/2022] Open
Abstract
Background: The effect on functional and quality of life (QOL) outcomes of surgery in elderly degenerative cervical myelopathy (DCM) patients has not been definitively established. Objective: To evaluate the effect of older age on the functional and QOL outcomes after surgery in an international, multi-center cohort of patients with DCM. Methods: 107 patients aged over 70 years old (mean 75.6 ± 4.4 years) were enrolled in the AOSpine CSM-North America and International studies. A propensity-matched cohort of 107 patients was generated from the remaining 650 adults aged <70 years old (mean 56.3 ± 9.6 years), matched to gender, complexity of surgery, co-morbidities, and baseline functional impairment (modified Japanese Orthopedic Association scale (mJOA). Functional, disability, and QOL outcomes were compared at baseline and at two years post-operatively, along with peri-operative adverse events. Results: Both cohorts were equivalently matched. At two years, both cohorts showed significant functional improvement from the baseline but the magnitude was greater in the younger cohort (mJOA 3.8 (3.2–4.4) vs. 2.6 (2.0–3.3); p = 0.007). This difference between groups was also observed in the SF-36 physical component summary (PCS) and mental component summary (MCS) outcomes (p = <0.001, p = 0.007), but not present in the neck disability index (NDI) scores (p = 0.094). Adverse events were non-significantly higher in the elderly cohort (22.4% vs. 15%; p = 0.161). Conclusions: Elderly patients showed an improvement in functional and QOL outcomes after surgery for DCM, but the magnitude of improvement was less when compared to the matched younger adult cohort. An age over 70 was not associated with an increased risk of adverse events.
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Affiliation(s)
- Jamie R F Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T2S8, Canada.
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5T2S8, Canada.
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T2S8, Canada.
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5T2S8, Canada.
| | - Fan Jiang
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T2S8, Canada.
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5T2S8, Canada.
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T2S8, Canada.
- Division of Neurosurgery, St. Michael's Hospital, University Health Network, Toronto, ON M5B1W8, Canada.
| | - Branko Kopjar
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA 98195, USA.
| | - Alexander R Vaccaro
- Department of Orthopedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA 19107, USA.
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T2S8, Canada.
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON M5T2S8, Canada.
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240
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Badhiwala JH, Ahuja CS, Fehlings MG. Time is spine: a review of translational advances in spinal cord injury. J Neurosurg Spine 2019; 30:1-18. [PMID: 30611186 DOI: 10.3171/2018.9.spine18682] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
Acute traumatic spinal cord injury (SCI) is a devastating event with far-reaching physical, emotional, and economic consequences for patients, families, and society at large. Timely delivery of specialized care has reduced mortality; however, long-term neurological recovery continues to be limited. In recent years, a number of exciting neuroprotective and regenerative strategies have emerged and have come under active investigation in clinical trials, and several more are coming down the translational pipeline. Among ongoing trials are RISCIS (riluzole), INSPIRE (Neuro-Spinal Scaffold), MASC (minocycline), and SPRING (VX-210). Microstructural MRI techniques have improved our ability to image the injured spinal cord at high resolution. This innovation, combined with serum and cerebrospinal fluid (CSF) analysis, holds the promise of providing a quantitative biomarker readout of spinal cord neural tissue injury, which may improve prognostication and facilitate stratification of patients for enrollment into clinical trials. Given evidence of the effectiveness of early surgical decompression and growing recognition of the concept that "time is spine," infrastructural changes at a systems level are being implemented in many regions around the world to provide a streamlined process for transfer of patients with acute SCI to a specialized unit. With the continued aging of the population, central cord syndrome is soon expected to become the most common form of acute traumatic SCI; characterization of the pathophysiology, natural history, and optimal treatment of these injuries is hence a key public health priority. Collaborative international efforts have led to the development of clinical practice guidelines for traumatic SCI based on robust evaluation of current evidence. The current article provides an in-depth review of progress in SCI, covering the above areas.
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Affiliation(s)
- Jetan H Badhiwala
- 1Division of Neurosurgery, Department of Surgery, and.,2Institute of Medical Science, University of Toronto; and
| | - Christopher S Ahuja
- 1Division of Neurosurgery, Department of Surgery, and.,2Institute of Medical Science, University of Toronto; and.,3Department of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, and.,2Institute of Medical Science, University of Toronto; and.,3Department of Genetics and Development, Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
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241
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Davies B, Mowforth O, Sadler I, Aarabi B, Kwon B, Kurpad S, Harrop JS, Wilson JR, Grossman R, Fehlings MG, Kotter M. Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients. BMJ Open 2019; 9:e031486. [PMID: 31601597 PMCID: PMC6797315 DOI: 10.1136/bmjopen-2019-031486] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES To establish the recovery priorities of individuals suffering with degenerative cervical myelopathy (DCM). DESIGN A cross-sectional, observational study. SETTING Patients from across the world with a diagnosis of DCM accessed the survey over an 18-month period on Myelopathy.org, an international myelopathy charity. PARTICIPANTS 481 individuals suffering from DCM completed the online survey fully. MAIN OUTCOME MEASURES Functional recovery domains were established through qualitative interviews and a consensus process. Individuals were asked about their disease characteristics, including limb pain (Visual Analogue Scale) and functional disability (patient-derived version of the modified Japanese Orthopaedic Association score). Individuals ranked recovery domains (arm and hand function, walking, upper body/trunk function, sexual function, elimination of pain, sensation and bladder/bowel function) in order of priority. Priorities were analysed as the modal first priority and mean ranking. The influence of demographics on selection was analysed, with significance p<0.05. RESULTS Of 659 survey responses obtained, 481 were complete. Overall, pain was the most popular recovery priority (39.9%) of respondents, followed by walking (20.2%), sensation (11.9%) and arm and hand function (11.5%). Sexual function (5.7%), bladder and bowel (3.7%) and trunk function (3.5%) were chosen less frequently. When considering the average ranking of symptoms, while pain remained the priority (2.6±2.0), this was closely followed by walking (2.9±1.7) and arm/hand function (3.0±1.4). Sensation ranked lower (4.3±2.1). With respect to disease characteristics, overall pain remained the recovery priority, with the exception of patients with greater walking impairment (p<0.005) who prioritised walking, even among patients with lower pain scores. CONCLUSIONS This is the first study investigating patient priorities in DCM. The patient priorities reported provide an important framework for future research and will help to ensure that it is aligned with patient needs.
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Affiliation(s)
- Benjamin Davies
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Oliver Mowforth
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Bizhan Aarabi
- Division of Neurosurgery, University of Maryland, Baltimore, Maryland, USA
| | - Brian Kwon
- Department of Orthopaedics, University of British Columbia, Vancouver, UK
| | - Shekar Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - James S Harrop
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Robert Grossman
- Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA
| | | | - Mark Kotter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Anne McLaren Laboratory for Regenerative Medicine, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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242
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Badhiwala JH, Wilson JR, Kwon BK, Casha S, Fehlings MG. A Review of Clinical Trials in Spinal Cord Injury Including Biomarkers. J Neurotrauma 2019; 35:1906-1917. [PMID: 29888678 DOI: 10.1089/neu.2018.5935] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Acute traumatic spinal cord injury (SCI) entered the arena of prospective, randomized clinical trials almost 40 years ago, with the undertaking of the National Acute Spinal Cord Study (NASCIS) I trial. Since then, a number of clinical trials have been conducted in the field, spurred by the devastating physical, social, and economic consequences of acute SCI for patients, families, and society at large. Many of these have been controversial and attracted criticism. The current review provides a critical summary of select past and current clinical trials in SCI, focusing in particular on the findings of prospective, randomized controlled trials, the challenges and barriers encountered, and the valuable lessons learned that can be applied to future trials.
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Affiliation(s)
- Jetan H Badhiwala
- 1 Division of Neurosurgery, Department of Surgery, University of Toronto , Toronto, Ontario, Canada
| | - Jefferson R Wilson
- 1 Division of Neurosurgery, Department of Surgery, University of Toronto , Toronto, Ontario, Canada
| | - Brian K Kwon
- 2 Vancouver Spine Surgery Institute, Department of Orthopedics, University of British Columbia , Vancouver, British Columbia, Canada
| | - Steven Casha
- 3 Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary , Calgary, Alberta, Canada
| | - Michael G Fehlings
- 1 Division of Neurosurgery, Department of Surgery, University of Toronto , Toronto, Ontario, Canada
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243
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Cadotte DW, Akbar MA, Fehlings MG, Stroman PW, Cohen-Adad J. What Has Been Learned from Magnetic Resonance Imaging Examination of the Injured Human Spinal Cord: A Canadian Perspective. J Neurotrauma 2019; 35:1942-1957. [PMID: 30074873 DOI: 10.1089/neu.2018.5903] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Magnetic resonance imaging (MRI) has transformed the way surgeons and researchers study and treat spinal cord injury. In this narrative review, we explore the historical context of imaging the human spinal cord and describe how MRI has evolved from providing the first visualization of the human spinal cord in the 1980s to a remarkable set of imaging tools today. The article focuses in particular on the role of Canadian researchers to this field. We begin by outlining the clinical context of traumatic injury to the human spinal cord and describe why current MRI standards fall short when it comes to treating this disabling condition. Parts 2 and 3 of this work explore an exciting and dramatic shift in the use of MRI technology to aid in our understanding and treatment of traumatic injury to the spinal cord. We explore the use of functional imaging (part 2) and structural imaging (part 3) and explore how these techniques have evolved, how they are used, and the challenges that we face for continued refinement and application to patients who live with the neurological and functional deficits caused by injury to the delicate spinal cord.
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Affiliation(s)
- David W Cadotte
- 1 University of Calgary Spine Program, Division of Neurosurgery, Department of Clinical Neurosciences, University of Calgary , Foothills Medical Centre, Calgary, Alberta, Canada
| | - M Ali Akbar
- 2 Department of Surgery, Division of Neurosurgery and Spinal Program, Toronto Western Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Michael G Fehlings
- 2 Department of Surgery, Division of Neurosurgery and Spinal Program, Toronto Western Hospital, University of Toronto , Toronto, Ontario, Canada
| | - Patrick W Stroman
- 3 Centre for Neuroscience Studies, Queens University , Kingston, Ontario, Canada
| | - Julien Cohen-Adad
- 4 NeuroPoly Lab, Institute of Biomedical Engineering , Polytechnique Montreal, Montreal, Quebéc, Canada .,5 Functional Neuroimaging Unit, CRIUGM, Université de Montréal , Montreal, Quebéc, Canada
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244
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Furlan JC, Craven BC, Fehlings MG. Is there any gender or age-related discrepancy in the waiting time for each step in the surgical management of acute traumatic cervical spinal cord injury? J Spinal Cord Med 2019; 42:233-241. [PMID: 31573451 PMCID: PMC6781466 DOI: 10.1080/10790268.2019.1614291] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Context/Objective: Prior studies indicate that patient's gender and age can influence treatment choices during spine disease management. This study examines whether individual's gender and age at injury onset influence the waiting time for each step in the surgical management of patients with acute traumatic cervical spinal cord injury (atcSCI). Design: Retrospective cohort study. Setting: Quaternary spine trauma center. Participants: This study included consecutive individuals with atcSCI admitted from August/2002 to October/2008 who were enrolled in the Surgical Trial in Acute Spinal Cord Injury Study (STASCIS). Interventions: Spinal cord decompression. Outcome Measures: Data on the periods of time for each step in the surgical management were analyzed to explore the potential effects of gender and age at injury onset. Results: There were 64 individuals with atcSCI (17 women, 47 men; age range: 18-78 years; mean age: 50.5 ± 2.1 years). Older age was associated with longer stay in the acute spine center, but this association was cofounded by major pre-existing medical co-morbidities. Age did not significantly affect the waiting time for each step in the surgical management of these individuals with atcSCI. Women underwent surgical assessment earlier than men. Gender did not influence other key steps in the surgical management. Conclusion: The study results suggest that older age at injury onset was associated with longer stay in the acute spine care center, and women had a shorter waiting time for surgical assessment than men. Nevertheless, no other age or gender bias was identified in the waiting times for the steps in the management of atcSCI.
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Affiliation(s)
- Julio C. Furlan
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada,Correspondence to: Julio C. Furlan, 520 Sutherland Drive, Room 206-J, Toronto, Ontario, Canada, M4G 3V9; Ph:416-597-4322 (Ext. 6129); 416-425-9923. E-mail:
| | - B. Catharine Craven
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Canada,Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Michael G. Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Canada,Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Canada
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245
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Furlan JC, Craven BC, Fehlings MG. Sex-related discrepancies in the epidemiology, injury characteristics and outcomes after acute spine trauma: A retrospective cohort study. J Spinal Cord Med 2019; 42:10-20. [PMID: 31573442 PMCID: PMC6781464 DOI: 10.1080/10790268.2019.1607055] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Context/Objective: The potential effects of sex on injury severity and outcomes after acute spine trauma (AST) have been reported in pre-clinical and clinical studies, even though the data are conflicting. This study compared females and males regarding the epidemiology, injury characteristics, and clinical outcomes of AST. Design: Retrospective cohort study. Setting: Acute spine care quaternary center. Participants: All consecutive cases of AST admitted from January/1996 to December/2007 were included. Interventions: None. Outcome Measures: The potential effects of sex on the epidemiology, injury characteristics, and clinical outcomes of AST were studied. Results: There were 504 individuals with AST (161 females, 343 males; mean age of 49.44 ± 0.92 years). Sex was not associated with age or pre-existing co-morbidities as assessed using the Charlson Co-morbidity Index, however, females had a greater number of International Classifications of Diseases (ICD) codes at admission and higher Cumulative Illness Rating Scale (CIRS) than males. Over the 12-year period, the male-to-female ratio has not significantly changed. Although there were significant sex-related discrepancies regarding injury etiology, level and severity of AST, males and females had similar lengths of stay in the acute spine center, in-hospital survival post-AST, and need for mechanical ventilation and tracheostomy. Conclusion: This study suggests that females with AST present with a greater number of pre-existing co-morbidities, a higher frequency of thoraco-lumbar trauma, less severe neurological impairment and a greater proportion of MVA-related injuries. However, females and males have a similar length of stay in the acute spine center, and comparable in-hospital survival, need for mechanical ventilation, and tracheostomy after AST.
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Affiliation(s)
- Julio C. Furlan
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada,Correspondence to: Julio C. Furlan, Lyndhurst Centre, Toronto Rehabilitation Institute, University Health Network, 520 Sutherland Drive, Room 206J, Toronto, Ontario M4G 3V9, Canada; Ph: 416-597-4322 (Ext. 6129), 416-425-9923.
| | - B. Catharine Craven
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada,KITE, Toronto Rehab – University Health Network, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada,Spinal Program, Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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246
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Sharif-Alhoseini M, Azadmanjir Z, Sadeghi-Naini M, Ghodsi Z, Naghdi K, Mohammadzadeh M, AzarHomayoun A, Zendehdel K, Khormali M, Sadeghian F, Jazayeri SB, Sehat M, Pirnejad H, Benzel EC, O'Reilly G, Fehlings MG, Vaccaro AR, Rahimi-Movaghar V. National Spinal Cord Injury Registry of Iran (NSCIR-IR) - a critical appraisal of its strengths and weaknesses. Chin J Traumatol 2019; 22:300-303. [PMID: 31445798 PMCID: PMC6823677 DOI: 10.1016/j.cjtee.2019.05.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/19/2019] [Accepted: 06/05/2019] [Indexed: 02/04/2023] Open
Abstract
The National Spinal Cord Injury Registry of Iran (NSCIR-IR) is a not-for-profit, hospital-based, and prospective observational registry that appraises the quality of care, long-term outcomes and the personal and psychological burden of traumatic spinal cord injury in Iran. Benchmarking validity in every registry includes rigorous attention to data quality. Data quality assurance is essential for any registry to make sure that correct patients are being enrolled and that the data being collected are valid. We reviewed strengths and weaknesses of the NSCIR-IR while considering the methodological guidelines and recommendations for efficient and rational governance of patient registries. In summary, the steering committee, funded and maintained by the Ministry of Health and Medical Education of Iran, the international collaborations, continued staff training, suitable data quality, and the ethical approval are considered to be the strengths of the registry, while limited human and financial resources, poor interoperability with other health systems, and time-consuming processes are among its main weaknesses.
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Affiliation(s)
- Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Azadmanjir
- Department of Health Information Management, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Sadeghi-Naini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Ghodsi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Khatereh Naghdi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Amir AzarHomayoun
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Zendehdel
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Moein Khormali
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Farideh Sadeghian
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Seyed Behzad Jazayeri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Sehat
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Habibollah Pirnejad
- Department of Health Information Technology, Urmia University of Medical Sciences, Urmia, Iran
| | - Edward C. Benzel
- Cleveland Clinic Foundation, Department of Neurosurgery, Cleveland, OH, USA
| | - Gerard O'Reilly
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, USA
| | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran,Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran,Corresponding author. Sina Trauma and Surgery Research Center, Sina Hospital, Hassan-Abad Square, Imam Khomeini Ave, Tehran, 11365-3876, Iran.
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247
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Badhiwala JH, Wilson JR, Fehlings MG. The case for revisiting central cord syndrome. Spinal Cord 2019; 58:125-127. [DOI: 10.1038/s41393-019-0354-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/01/2019] [Accepted: 08/16/2019] [Indexed: 11/09/2022]
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248
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Arnold PM, Sasso RC, Janssen ME, Fehlings MG, Heary RF, Vaccaro AR, Kopjar B. i-Factor™ Bone Graft vs Autograft in Anterior Cervical Discectomy and Fusion: 2-Year Follow-up of the Randomized Single-Blinded Food and Drug Administration Investigational Device Exemption Study. Neurosurgery 2019; 83:377-384. [PMID: 28945914 DOI: 10.1093/neuros/nyx432] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 08/09/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND i-Factor™ Bone Graft (Cerapedics Inc, Westminster, Colorado) is a composite bone substitute material consisting of P-15 synthetic collagen fragment adsorbed onto anorganic bone mineral suspended in an inert biocompatible hydrogel carrier. A pivotal, noninferiority, US FDA Investigational Device Exemption study demonstrated the benefits of i-Factor™ compared to local autograft bone in single-level anterior cervical discectomy and fusion at 1-yr postoperative. OBJECTIVE To report 2-yr follow-up. METHODS Subjects randomly received either autograft (n = 154) or i-Factor™ (n = 165) in a cortical ring allograft and followed using radiological, clinical, and patient-reported outcomes. RESULTS At 2 yr, the fusion rate was 97.30% and 94.44% in i-Factor™ and autograft subjects, respectively (P = .2513), and neurological success rate was 94.87% (i-Factor™) and 93.79% (autograft; P = .7869). Neck Disability Index improved 28.30 (i-Factor™) and 26.95 (autograft; P = .1448); Visual Analog Scale arm pain improved 5.43 (i-Factor™) and 4.97 (autograft) (p = .2763); Visual Analog Scale neck pain improved 4.78 (i-Factor™) and 4.41 (autograft; P = .1652), Short Form-36 (SF-36v2) Physical Component Score improved 10.23 (i-Factor™) and 10.18 (autograft; P = .4507), and SF36v2 Mental Component Score improved 7.88 (i-FactorTM) and 7.53 (autograft; P = .9872). The composite endpoint of overall success (fusion, Neck Disability Index improvement >15, neurological success, and absence of re-operations) was greater in i-Factor™ subjects compared to autograft subjects (69.83% and 56.35%, respectively, P = .0302). Twelve (7.45%) i-Factor™ subjects and 16 (10.53%) autograft subjects underwent re-operation (P = .3411). There were no allergic reactions associated with i-Factor™. CONCLUSION Use of i-Factor™ in anterior cervical discectomy and fusion is effective and safe, and results in similar outcomes compared to local autograft bone at 2 yr following surgery.
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Affiliation(s)
- Paul M Arnold
- Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | | | - Michael G Fehlings
- Department of Neurosurgery, University of Toronto, The Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Robert F Heary
- Department of Neurological Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Alexander R Vaccaro
- Rothman Institute Orthopaedics, Thomas Jefferson University Hospital, Philadelphia Pennsylvania
| | - Branko Kopjar
- Department of Health Services, University of Washington, Seattle, Washington
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249
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Levi AD, Okonkwo DO, Park P, Jenkins AL, Kurpad SN, Parr AM, Ganju A, Aarabi B, Kim D, Casha S, Fehlings MG, Harrop JS, Anderson KD, Gage A, Hsieh J, Huhn S, Curt A, Guzman R. Emerging Safety of Intramedullary Transplantation of Human Neural Stem Cells in Chronic Cervical and Thoracic Spinal Cord Injury. Neurosurgery 2019; 82:562-575. [PMID: 28541431 DOI: 10.1093/neuros/nyx250] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/18/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Human central nervous system stem cells (HuCNS-SC) are multipotent adult stem cells with successful engraftment, migration, and region-appropriate differentiation after spinal cord injury (SCI). OBJECTIVE To present data on the surgical safety profile and feasibility of multiple intramedullary perilesional injections of HuCNS-SC after SCI. METHODS Intramedullary free-hand (manual) transplantation of HuCNS-SC cells was performed in subjects with thoracic (n = 12) and cervical (n = 17) complete and sensory incomplete chronic traumatic SCI. RESULTS Intramedullary stem cell transplantation needle times in the thoracic cohort (20 M HuCNS-SC) were 19:30 min and total injection time was 42:15 min. The cervical cohort I (n = 6), demonstrated that escalating doses of HuCNS-SC up to 40 M range were well tolerated. In cohort II (40 M, n = 11), the intramedullary stem cell transplantation needle times and total injection time was 26:05 ± 1:08 and 58:14 ± 4:06 min, respectively. In the first year after injection, there were 4 serious adverse events in 4 of the 12 thoracic subjects and 15 serious adverse events in 9 of the 17 cervical patients. No safety concerns were considered related to the cells or the manual intramedullary injection. Cervical magnetic resonance images demonstrated mild increased T2 signal change in 8 of 17 transplanted subjects without motor decrements or emerging neuropathic pain. All T2 signal change resolved by 6 to 12 mo post-transplant. CONCLUSION A total cell dose of 20 M cells via 4 and up to 40 M cells via 8 perilesional intramedullary injections after thoracic and cervical SCI respectively proved safe and feasible using a manual injection technique.
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Affiliation(s)
- Allan D Levi
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Arthur L Jenkins
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Shekar N Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ann M Parr
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota
| | - Aruna Ganju
- Department of Neurological Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland, College Park, Maryland
| | - Dong Kim
- Department of Neurosurgery, University of Texas Health Science Center, Austin, Texas
| | - Steven Casha
- Department of Clinical Neurosciences and the Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spinal Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Kim D Anderson
- Department of Neurological Surgery and the Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | | | - Armin Curt
- Spinal Cord Injury Unit, Balgrist University Hospital, Zürich, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, Basel, Switzerland
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250
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Nouri A, Tetreault L, Nori S, Martin AR, Nater A, Fehlings MG. Congenital Cervical Spine Stenosis in a Multicenter Global Cohort of Patients With Degenerative Cervical Myelopathy: An Ambispective Report Based on a Magnetic Resonance Imaging Diagnostic Criterion. Neurosurgery 2019; 83:521-528. [PMID: 29462433 DOI: 10.1093/neuros/nyx521] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 02/09/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Congenital spinal stenosis (CSS) of the cervical spine is a risk factor for acute spinal cord injury and development of degenerative cervical myelopathy (DCM). OBJECTIVE To develop magnetic resonance imaging (MRI)-based criteria to diagnose preexisting CSS and evaluate differences between patients with and without CSS. METHODS A secondary analysis of international prospectively collected data between 2005 and 2011 was conducted. We examined the data of 349 surgical DCM patients and 27 controls. Spinal canal and cord anteroposterior diameters were measured at noncompressed sites to calculate spinal cord occupation ratio (SCOR). Torg-Pavlov ratios and spinal canal diameters from radiographs were correlated with SCOR. Clinical and MRI factors were compared between patients with and without CSS. Surgical outcomes were also assessed. RESULTS Calculation of SCOR was feasible in 311/349 patients. Twenty-six patients with CSS were identified (8.4%). Patients with CSS were younger than patients without CSS (P = .03) and had worse baseline severity as measured by the modified Japanese Orthopedic Association score (P = .04), Nurick scale (P = .05), and Neck Disability Index (P < .01). CSS patients more commonly had T2 cord hyperintensity changes (P = .09, ns) and worse SF-36 Physical Component scores (P = .06, ns). SCOR correlated better with Torg-Pavlov ratio and spinal canal diameter at C3 than C5. Patients with SCOR ≥ 65% were also younger but did not differ in baseline severity. CONCLUSION SCOR ≥ 70% is an effective criterion to diagnose CSS. CSS patients develop myelopathy at a younger age and have greater impairment and disability than other patients with DCM. Despite this, CSS patients have comparable duration of symptoms, MRI presentations, and surgical outcomes to DCM patients without CSS.
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Affiliation(s)
- Aria Nouri
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Lindsay Tetreault
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Satoshi Nori
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Allan R Martin
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Anick Nater
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
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