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Boddeti U, Polavarapu H, Patel S, Choudhary A, Langbein J, Nusraty S, Vatsa S, Brahmbhatt P, Mitha R. Current Status of Awake Spine Surgery: A Bibliometric Analysis. World Neurosurg 2024:S1878-8750(24)00749-6. [PMID: 38719075 DOI: 10.1016/j.wneu.2024.04.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Spine surgery accounts for a large proportion of neurosurgical procedures, with approximately 313 million spine surgeries conducted annually worldwide. Considering delayed recovery and postoperative complications that are commonly reported, there has been a recent shift toward minimally invasive spine procedures conducted under local anesthesia. Despite proven success, there exists a limited body of literature on the use of awake surgery in spinal procedures. METHODS A bibliometric analysis was conducted to map the current landscape of work in this field. 190 articles were identified from the Web of Science (Clarivate, NY) database. A comprehensive bibliometric analysis was performed on a narrowed list of the most relevant articles using Bibliometrix, an R-based programming tool. RESULTS There has been a rise in academic papers published on the topic of awake spine surgery since 2016, with an increase in publication count by approximately 18% annually and each article cited approximately ten times on average to date. The year 2022 saw an uptick in publications, with 9 throughout the entire year. The most impactful article, with a total of 95 citations, was published by Sairyo et al.1 Thematic analysis revealed that the terms "lumbar spine" and "stenosis" are well-developed topics in the literature, whereas the topics of "complications," "fusion," and "cost-analysis" are less well-developed topics. CONCLUSIONS This study provides a comprehensive overview of the most-cited articles in the field of awake spine surgery. Specifically, it identifies areas that are well represented in the literature and those which are underrepresented and should be areas of continued future research.
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Affiliation(s)
- Ujwal Boddeti
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Hanish Polavarapu
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shrey Patel
- Department of Neurosurgery, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Aditi Choudhary
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jenna Langbein
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sabrina Nusraty
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sonika Vatsa
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Priya Brahmbhatt
- Rowan University School of Osteopathic Medicine, Stratford, New Jersey, USA
| | - Rida Mitha
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Salven D, Sykes D, Erickson M, Than K, Grossi P, Crutcher C, Berger M, Bullock WM, Gadsden J, Abd-El-Barr M. Regional anesthesia in spine surgery: A narrative review. JOURNAL OF SPINE PRACTICE (JSP) 2023:40-50. [DOI: 10.18502/jsp.v2i2.13223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background: Regional anesthesia, which refers to the use of anesthetics to provide analgesia to a specific body part or nervous innervation territory, has become increasingly popular in the field of spine surgery. With the application of these techniques, it has been postulated that patients will require less systemic analgesia, intraoperatively and postoperatively. The authors of this narrative review discuss the common regional anesthetic modalities applied to spine surgery, in addition to patient selection criteria, success in patients with multiple comorbid illnesses, and its adoption by surgeons.
Materials and Methods: An advanced search was performed in the PubMed database to obtain Englishlanguage articles discussing regional anesthesia, awake spine surgery, and postoperative complications. Articles were screened for relevance, and 47 articles were incorporated into this narrative review.
Results: Classic neuraxial and paraspinal techniques have allowed surgeons to perform posterior decompression, fusion, and revision procedures. Transversus abdominus plane and quadratus lumborum blocks have enabled better pain control in patients undergoing surgeries requiring anterior or lateral approaches. Documented benefits of regional anesthesia include shorter operative time, improved pain control and hemodynamic stability, as well as decreased cost and length of stay. Several case series have demonstrated the success of these techniques in highly comorbid patients.
Conclusion: Regional anesthesia provides an exciting opportunity to make surgical treatment possible for spine patients with significant comorbidities. Although additional randomized controlled trials are necessary to further refine patient selection criteria, current data demonstrates its safety and efficacy in the operating room.
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Safa A, De Biase G, Gassie K, Garcia D, Abode-Iyamah K, Chen SG. Reliability of YouTube videos on robotic spine surgery for patient education. J Clin Neurosci 2023; 109:6-10. [PMID: 36634473 DOI: 10.1016/j.jocn.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/15/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Robotic surgical systems developed to improve spine surgery accuracy. Studies have found significant reductions in screw revisions and radiation exposure with robotic assistance compared with open surgery. YouTube is the largest online video platform for medical education. Therefore, there is a need for the continuous critical assessment of healthcare-related YouTube videos. Our objective is to assess the reliability of YouTube videos on robotic spine surgery for patient education. METHODS In April of 2022, YouTube was queried for the following keywords: "Robotic Spine Surgery". The "Relevance-Based Ranking" filter was applied, and the first 3 result pages were considered. Videos had to be uploaded by universities or hospitals and be in the English. Three independent healthcare personnel evaluated the videos' education quality using the DISCERN tool. RESULTS Our study found that 33 % of videos analyzed scored above a 3 on the DISCERN scoring scale (considered a ''good" video), with overall mean DISCERN score of 2.8 ± 1.3 (SD). The duration of videos was significantly different between the two groups (Good = 16 min ± 21 vs Unhelpful = 4 min ± 4, p = 0.01). In the helpful group, other characteristics were number of views (16331 ± 31308), likes (88 ± 168) and dislikes (5 ± 8). No statistically significant differences were observed compared to the unhelpful group: number of views (6515 ± 9074; P = 0.20), likes (39 ± 55; P = 0.21) and dislikes (3 ± 4; P = 0.33). CONCLUSION Our study shows that YouTube videos on robotic spine surgery lack accuracy and have poor educational value. There should be increased institutional oversight to combat the spread of misinformation.
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Affiliation(s)
- Adrian Safa
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Gaetano De Biase
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Kelly Gassie
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Diogo Garcia
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Selby G Chen
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
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El-Ghandour NMF. Commentary: The "In-Parallel" Technique for Awake, Bilateral Simultaneous Minimally Invasive Transforaminal Lumbar Interbody Fusion and Multilevel Lumbar Decompression. Oper Neurosurg (Hagerstown) 2023; 24:e170-e171. [PMID: 36701692 DOI: 10.1227/ons.0000000000000600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 01/27/2023] Open
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De Biase G, Carter RE, Otamendi-Lopez A, Garcia D, Chen S, Bojaxhi E, Quinones-Hinojosa A, Abode-Iyamah K. Assessment of surgeons' attitude towards awake spine surgery under spinal anesthesia. J Clin Neurosci 2023; 107:48-53. [PMID: 36502781 DOI: 10.1016/j.jocn.2022.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND General anesthesia (GA) and spinal anesthesia (SA) have been adopted for lumbar spine surgery (LSS), but GA is used far more widely. We conducted a survey of spine surgeons to explore their attitudes and preferences regarding awake spine surgery under SA. METHODS A survey was emailed to 150 spine surgeons. Exposure and attitudes towards spine surgery under SA were elicited. A five-point Likert scale of agreement examined perceptions of SA, while attitudes towards SA were recorded by categorizing free text into themes. RESULTS Seventy-five surgeons completed the survey, 50 % response rate. Only 27 % said they perform LSS under SA. Most surgeons, 83 %, would recommend GA to a healthy patient undergoing lumbar laminectomy. Only 41 % believes SA to be as safe as GA, and only 30 % believes SA is associated with better postoperative pain control. The most common reasons why SA is not favored was lack of proven benefits over GA (65 %). When asked if a randomized trial finds SA to lead to less postoperative fatigue, 50 % said they would be more likely to offer SA, a significant increase from the baseline response of 27 % (p = 0.002). CONCLUSIONS Our survey indicates that the low adoption of SA for LSS is due to lack of surgeons' belief in the benefits of SA over GA, and that a randomized patient-centered trial has the potential of changing surgeons' perspective and increasing adoption of SA for LSS.
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Affiliation(s)
| | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, FL, USA
| | | | - Diogo Garcia
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Selby Chen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic, Jacksonville, FL, USA
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Waguia R, Touko EK, Sykes DA, Kelly-Hedrick M, Hijji FY, Sharan AD, Foster N, Abd-El-Barr MM. How to start an awake spine program: Protocol and illustrative cases. IBRO Neurosci Rep 2022; 13:69-77. [PMID: 35789808 PMCID: PMC9249618 DOI: 10.1016/j.ibneur.2022.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/31/2022] [Indexed: 11/15/2022] Open
Abstract
Surgical techniques and technology are steadily improving, thereby expanding the pool of patients amenable for spine surgery. The growing and aging population in the United States further contributes to the increase in spine surgery cases. Traditionally, spine surgery is performed under general anesthesia. However, awake spinal surgery has recently gained traction due to evidence of decreased perioperative risks, postoperative opioid consumption, and costs, specifically in lumbar spine procedures. Despite the potential for improving outcomes, awake spine surgery has received resistance and has yet to become adopted at many healthcare systems. We aim to provide the fundamental steps in facilitating the initiation of awake spine surgery programs. We also present case reports of two patients who underwent awake spine surgery and reported improved clinical outcomes. Starting an Awake Spine program is feasible and may improve clinical outcomes. Awake Spine Surgery is associated with reduced cardiopulmonary complications and opioid consumption. Awake Spine Surgery is effective at reducing LOS, HAC, and cost of surgery. Awake Spine Surgery increases the pool of patients eligible for spinal procedures.
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Gami P, Qiu K, Kannappan S, Alperin Y, Biase GD, Buchanan IA, Quiñones-Hinojosa A, Abode-Iyamah K. Semiautomated intraoperative measurement of Cobb angle and coronal C7 plumb line using deep learning and computer vision for scoliosis correction: a feasibility study. J Neurosurg Spine 2022; 37:713-721. [PMID: 36303475 DOI: 10.3171/2022.4.spine22133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is a degenerative disease with a 3D deformity in the alignment of the spinal column. Surgical spinal correction outcomes are heavily dependent on the surgeon's expertise and use of visual cues because of time requirements, lack of automation, and radiation exposure associated with current intraoperative measurement techniques. In this study, the authors sought to validate a novel, nonradiographic, and semiautomated device that measures spinal alignment intraoperatively using deep learning and computer vision. METHODS To obtain spinal alignment metrics intraoperatively, the surgeon placed 3D-printed markers made of acrylonitrile butadiene styrene (ABS) plastic at designated locations in the surgical field. With the high-definition camera of the device, the surgeon can take an image of the markers in the surgical field. Images are processed through a computer vision model that detects the location of the markers and calculates the Cobb angle and coronal plumb line. The marker detection model was trained on 100 images and tested on 130 images of the ABS markers in various conditions. To verify the Cobb angle calculation, 50 models of angle templates from 0° to 180° in 3.6735° increments were created for testing. To verify the plumb line calculation, 21 models of plumb line measurements from -10 to +10 cm in increments of 1 cm were created for testing. A validation study was performed on a scoliotic cadaver model, and the radiographic calculations for Cobb angle and plumb line were compared with the device's calculations. RESULTS The area under the curve for the marker detection model was 0.979 for Cobb angle white, 0.791 for Cobb angle black, and 1 for the plumb line model. The average absolute difference between expected and measured Cobb angles on the verification models was 1.726° ± 1.259°, within the clinical acceptable error of 5°. The average absolute difference between the expected and measured plumb lines on the verification models was 0.415 ± 0.255 cm. For the cadaver validation study, the differences between the radiographic and device calculations for the Cobb angle and plumb line were 2.78° and 0.29 cm, respectively. CONCLUSIONS The authors developed and validated a nonradiographic, semiautomated device that utilizes deep learning and computer vision to measure spinal metrics intraoperatively.
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Affiliation(s)
- Parth Gami
- 1Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia; and
| | - Kelly Qiu
- 1Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia; and
| | - Sindhu Kannappan
- 1Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia; and
| | - Yoel Alperin
- 1Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia; and
| | | | - Ian A Buchanan
- 2Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
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De Biase G, Chen S, Ziu E, Garcia D, Bojaxhi E, Carter RE, Quinones-Hinojosa A, Abode-Iyamah K. Assessment of Patients' Willingness to Participate in a Randomized Trial of Spinal versus General Anesthesia for Lumbar Spine Surgery. World Neurosurg 2022; 161:e635-e641. [PMID: 35217226 DOI: 10.1016/j.wneu.2022.02.071] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Prospective nonrandomized studies have found less postoperative fatigue and improved quality of life in patients undergoing awake spine surgery under spinal anesthesia compared with general anesthesia. Randomized trials are needed to validate these findings. OBJECTIVE To prospectively investigate patients' willingness to enroll in randomized trials of lumbar spine surgery under spinal versus general anesthesia and identify any potential barriers. METHODS We recruited patients undergoing lumbar spine surgery for degenerative disease. We described a randomized trial of spine surgery under spinal versus general anesthesia and assessed patients' willingness to participate in such trial. We elicited preferences for treatment along with demographics. The association between these factors and willingness to participate in the trial was examined. RESULTS Fifty patients completed interviews; 58% were female, mean age of 60.9 ± 12.5 years. A total of 52% patients stated that they were definitely willing to participate in the hypothetical randomized trial, and 8% probably willing. Only 16% of patients were aware of spinal anesthesia as an option for low back surgery, and 60% indicated no strong preference for the anesthesia techniques. Patients without strong preferences stated a greater willingness to participate than those with strong preferences (80% vs. 10% definitely willing, P < 0.0001). Age, sex, education, work status, and race were not significantly associated with willingness to participate. CONCLUSION Sixty percent of patients stated that they were either definitely or probably willing to participate in the randomized trial. Subjects lacking strong preferences for the anesthesia technique stated a greater willingness to enroll than those with strong preference.
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Affiliation(s)
- Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Selby Chen
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Endrit Ziu
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Diogo Garcia
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Rickey E Carter
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
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Letchuman V, Agarwal N, Mummaneni VP, Wang MY, Shabani S, Patel A, Rivera J, Haddad A, Le V, Chang JM, Chou D, Gandhi S, Mummaneni PV. Pearls and pitfalls of awake spine surgery: A simplified patient-selection algorithm. World Neurosurg 2022; 161:154-155. [PMID: 35217225 DOI: 10.1016/j.wneu.2022.02.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Vijay Letchuman
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Nitin Agarwal
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
| | - Valli P Mummaneni
- Department of Anesthesiology, University of California, San Francisco, San Francisco, California, USA
| | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, Florida, USA
| | - Saman Shabani
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Arati Patel
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joshua Rivera
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Alexander Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Vivian Le
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joyce M Chang
- Department of Anesthesiology, University of California, San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Seema Gandhi
- Department of Anesthesiology, University of California, San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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De Biase G, Gruenbaum SE, Quiñones-Hinojosa A, Abode-Iyamah KO. Spine Surgery Under Spinal vs General Anesthesia: Prospective Analysis of Quality of Life, Fatigue, and Cognition. Neurosurgery 2022; 90:186-191. [PMID: 34995217 DOI: 10.1227/neu.0000000000001777] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/31/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND There has recently been increasing interest in the use of spinal anesthesia (SA) for spine surgery. The literature that compared spine surgery under SA vs general anesthesia (GA) focused on safety, perioperative outcomes, and costs. OBJECTIVE To test if SA is associated with less postoperative fatigue, cognitive dysfunction, and better quality of life in patients undergoing lumbar spine surgery compared with GA. METHODS We conducted a prospective nonrandomized study in patients undergoing elective lumbar spine surgery under SA or GA by a single surgeon. Fatigue was assessed with the fatigue visual analog scale scale (0-10) and Chalder Fatigue Scale, quality of life with Medical Outcomes Study 12-item Short Form (SF-12), and differences in cognition with Mini-Mental State Examination. Patients were baselined before surgery and assessed again 1 mo after surgery. RESULTS Fifty patients completed the study, 25 underwent surgery under SA and 25 under GA. The groups were homogeneous for baseline clinical characteristics, with no differences in preoperative fatigue, quality of life, and cognition. At 1 mo after surgery, SA compared with GA had better fatigue scores: fatigue visual analog scale (2.9 ± 1.5 vs 5.9 ± 2.3 [P < .0001]) and Chalder Fatigue Scale (11.2 ± 3.1 vs 16.9 ± 3.9 [P < .0001]). One month postoperatively, we observed a significant difference in the SF-12 physical component, with SA having 38.8 ± 8.9 vs 29.4 ± 10.3 (P = .002). We did not observe significant postoperative differences in the SF-12 mental component or Mini-Mental State Examination. CONCLUSION Our study demonstrates that SA offers unique patient-centered advantages to GA for elective spine surgery. One month after surgery, patients who received SA had less postoperative fatigue and better quality of life.
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Affiliation(s)
- Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Shaun E Gruenbaum
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
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Garcia D, Akinduro OO, De Biase G, Sousa-Pinto B, Jerreld DJ, Dholakia R, Borah B, Nottmeier E, Deen HG, Fox WC, Bydon M, Chen S, Quinones-Hinojosa A, Abode-Iyamah K. Robotic-Assisted vs Nonrobotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Cost-Utility Analysis. Neurosurgery 2022; 90:192-198. [PMID: 35023874 DOI: 10.1227/neu.0000000000001779] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/01/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Management of degenerative disease of the spine has evolved to favor minimally invasive techniques, including nonrobotic-assisted and robotic-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Value-based spending is being increasingly implemented to control rising costs in the US healthcare system. With an aging population, it is fundamental to understand which procedure(s) may be most cost-effective. OBJECTIVE To compare robotic and nonrobotic MIS-TLIF through a cost-utility analysis. METHODS We considered direct medical costs related to surgical intervention and to the hospital stay, as well as 1-yr utilities. We estimated costs by assessing all cases involving adults undergoing robotic surgery at a single institution and an equal number of patients undergoing nonrobotic surgery, matched by demographic and clinical characteristics. We adopted a willingness to pay of $50 000/quality-adjusted life year (QALY). Uncertainty was addressed by deterministic and probabilistic sensitivity analyses. RESULTS Costs were estimated based on a total of 76 patients, including 38 undergoing robot-assisted and 38 matched patients undergoing nonrobot MIS-TLIF. Using point estimates, robotic surgery was projected to cost $21 546.80 and to be associated with 0.68 QALY, and nonrobotic surgery was projected to cost $22 398.98 and to be associated with 0.67 QALY. Robotic surgery was found to be more cost-effective strategy, with cost-effectiveness being sensitive operating room/materials and room costs. Probabilistic sensitivity analysis identified robotic surgery as cost-effective in 63% of simulations. CONCLUSION Our results suggest that at a willingness to pay of $50 000/QALY, robotic-assisted MIS-TLIF was cost-effective in 63% of simulations. Cost-effectiveness depends on operating room and room (admission) costs, with potentially different results under distinct neurosurgical practices.
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Affiliation(s)
- Diogo Garcia
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Gaetano De Biase
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Bernardo Sousa-Pinto
- MEDCIDS - Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal.,CINTESIS - Center for Health Technology and Services Research, University of Porto, Porto, Portugal
| | - Daniel J Jerreld
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ruchita Dholakia
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Delivery Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan Borah
- Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Health Care Delivery Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric Nottmeier
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - H Gordon Deen
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - W Christopher Fox
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Selby Chen
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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12
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Abode-Iyamah K, Ghaith AK, Bhandarkar AR, De Biase G, Rajjoub R, Chen SG, Quiñones-Hinojosa A, Bydon M. Single-level awake transforaminal lumbar interbody fusion: a Mayo Clinic institutional experience and national analysis. Neurosurg Focus 2021; 51:E4. [PMID: 34852317 DOI: 10.3171/2021.9.focus21457] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Awake transforaminal lumbar interbody fusion (TLIF) is a novel technique for performing spinal fusions in patients under conscious sedation. Whether awake TLIF can reduce operative times and decrease the hospital length of stay (LOS) remains to be shown. In this study, the authors sought to assess the differences in clinical outcomes between patients who underwent awake TLIF and those who underwent TLIF under general anesthesia by using institutional experience at the Mayo Clinic and the National Surgical Quality Improvement Program (NSQIP) database. METHODS Chart review was performed for a consecutive series of patients who underwent single-level minimally invasive surgery (MIS)-TLIF performed by a single surgeon (K.A.I.) at a single institution. Additionally, the NSQIP database was queried from 2016 to 2019 for patients who underwent awake TLIF as well as propensity score-matched patients who underwent TLIF under general anesthesia. RESULTS A total of 20 patients at Mayo Clinic underwent awake single-level MIS-TLIF. The mean operative time was 122 ± 16.68 minutes, and the mean estimated blood loss was 39 ± 30.24 ml. No intraoperative complications were reported. A total of 96 patients who underwent TLIF (24 awake and 72 under general anesthesia) were analyzed from the NSQIP database. The mean LOS was less in the awake cohort (1.4 ± 1.381 days) than the general anesthesia cohort (3 ± 2.274 days) (p = 0.002). CONCLUSIONS Evidence from the authors' institutional experience and national analysis has demonstrated that awake MIS-TLIF is efficient and can reduce hospital LOS.
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Affiliation(s)
| | - Abdul Karim Ghaith
- 2Department of Neurosurgery, Mayo Clinic, Rochester; and.,3Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Archis R Bhandarkar
- 2Department of Neurosurgery, Mayo Clinic, Rochester; and.,3Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | - Rami Rajjoub
- 2Department of Neurosurgery, Mayo Clinic, Rochester; and.,3Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Selby G Chen
- 1Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | | | - Mohamad Bydon
- 2Department of Neurosurgery, Mayo Clinic, Rochester; and.,3Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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Letchuman V, Agarwal N, Mummaneni VP, Wang MY, Shabani S, Patel A, Rivera J, Haddad AF, Le V, Chang JM, Chou D, Gandhi S, Mummaneni PV. Awake spinal surgery: simplifying the learning curve with a patient selection algorithm. Neurosurg Focus 2021; 51:E2. [PMID: 34852318 DOI: 10.3171/2021.9.focus21433] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is a learning curve for surgeons performing "awake" spinal surgery. No comprehensive guidelines have been proposed for the selection of ideal candidates for awake spinal fusion or decompression. The authors sought to formulate an algorithm to aid in patient selection for surgeons who are in the startup phase of awake spinal surgery. METHODS The authors developed an algorithm for selecting patients appropriate for awake spinal fusion or decompression using spinal anesthesia supplemented with mild sedation and local analgesia. The anesthetic protocol that was used has previously been reported in the literature. This algorithm was formulated based on a multidisciplinary team meeting and used in the first 15 patients who underwent awake lumbar surgery at a single institution. RESULTS A total of 15 patients who underwent decompression or lumbar fusion using the awake protocol were reviewed. The mean patient age was 61 ± 12 years, with a median BMI of 25.3 (IQR 2.7) and a mean Charlson Comorbidity Index of 2.1 ± 1.7; 7 patients (47%) were female. Key patient inclusion criteria were no history of anxiety, 1 to 2 levels of lumbar pathology, moderate stenosis and/or grade I spondylolisthesis, and no prior lumbar surgery at the level where the needle is introduced for anesthesia. Key exclusion criteria included severe and critical central canal stenosis or patients who did not meet the inclusion criteria. Using the novel algorithm, 14 patients (93%) successfully underwent awake spinal surgery without conversion to general anesthesia. One patient (7%) was converted to general anesthesia due to insufficient analgesia from spinal anesthesia. Overall, 93% (n = 14) of the patients were assessed as American Society of Anesthesiologists class II, with 1 patient (7%) as class III. The mean operative time was 115 minutes (± 60 minutes) with a mean estimated blood loss of 46 ± 39 mL. The median hospital length of stay was 1.3 days (IQR 0.1 days). No patients developed postoperative complications and only 1 patient (7%) required reoperation. The mean Oswestry Disability Index score decreased following operative intervention by 5.1 ± 10.8. CONCLUSIONS The authors propose an easy-to-use patient selection algorithm with the aim of assisting surgeons with patient selection for awake spinal surgery while considering BMI, patient anxiety, levels of surgery, and the extent of stenosis. The algorithm is specifically intended to assist surgeons who are in the learning curve of their first awake spinal surgery cases.
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Affiliation(s)
- Vijay Letchuman
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Nitin Agarwal
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Valli P Mummaneni
- 2Department of Anesthesiology, University of California, San Francisco, California; and
| | - Michael Y Wang
- 3Department of Neurosurgery, University of Miami, Miami, Florida
| | - Saman Shabani
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Arati Patel
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Joshua Rivera
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Alexander F Haddad
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Vivian Le
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Joyce M Chang
- 2Department of Anesthesiology, University of California, San Francisco, California; and
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Seema Gandhi
- 2Department of Anesthesiology, University of California, San Francisco, California; and
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco
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14
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De Biase G, Gruenbaum SE, West JL, Chen S, Bojaxhi E, Kryzanski J, Quiñones-Hinojosa A, Abode-Iyamah K. Spinal versus general anesthesia for minimally invasive transforaminal lumbar interbody fusion: implications on operating room time, pain, and ambulation. Neurosurg Focus 2021; 51:E3. [PMID: 34852316 DOI: 10.3171/2021.9.focus21265] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/14/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There has been increasing interest in the use of spinal anesthesia (SA) for spine surgery, especially within Enhanced Recovery After Surgery (ERAS) protocols. Despite the wide adoption of SA by the orthopedic practices, it has not gained wide acceptance in lumbar spine surgery. Studies investigating SA versus general anesthesia (GA) in lumbar laminectomy and discectomy have found that SA reduces perioperative costs and leads to a reduction in analgesic use, as well as to shorter anesthesia and surgery time. The aim of this retrospective, case-control study was to compare the perioperative outcomes of patients who underwent minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) after administration of SA with those who underwent MIS-TLIF under GA. METHODS Overall, 40 consecutive patients who underwent MIS-TLIF by a single surgeon were analyzed; 20 patients received SA and 20 patients received GA. Procedure time, intraoperative adverse events, postoperative adverse events, postoperative length of stay, 3-hour postanesthesia care unit (PACU) numeric rating scale (NRS) pain score, opioid medication, and time to first ambulation were collected for each patient. RESULTS The two groups were homogeneous for clinical characteristics. A decrease in total operating room (OR) time was found for patients who underwent MIS-TLIF after administration of SA, with a mean OR time of 156.5 ± 18.9 minutes versus 213.6 ± 47.4 minutes for patients who underwent MIS-TLIF under GA (p < 0.0001), a reduction of 27%. A decrease in total procedure time was also observed for SA versus GA (122 ± 16.7 minutes vs 175.2 ± 10 minutes; p < 0.0001). No significant differences were found in intraoperative and postoperative adverse events. There was a difference in the mean maximum NRS pain score during the first 3 hours in the PACU as patients who received SA reported a lower pain score compared with those who received GA (4.8 ± 3.5 vs 7.3 ± 2.7; p = 0.018). No significant difference was observed in morphine equivalents received by the two groups. A difference was also observed in the mean overall NRS pain score, with 2.4 ± 2.1 for the SA group versus 4.9 ± 2.3 for the GA group (p = 0.001). Patients who received SA had a shorter time to first ambulation compared with those who received GA (385.8 ± 353.8 minutes vs 855.9 ± 337.4 minutes; p < 0.0001). CONCLUSIONS The results of this study have pointed to some important observations in this patient population. SA offers unique advantages in comparison with GA for performing MIS-TLIF, including reduced OR time and postoperative pain, and faster postoperative mobilization.
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Affiliation(s)
| | - Shaun E Gruenbaum
- 2Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida; and
| | - James L West
- 1Department of Neurosurgery, Mayo Clinic, Jacksonville
| | - Selby Chen
- 1Department of Neurosurgery, Mayo Clinic, Jacksonville
| | - Elird Bojaxhi
- 2Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida; and
| | - James Kryzanski
- 3Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
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15
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Minimally Invasive Transforaminal Lumbar Interbody Fusion: Cost of a Surgeon's Learning Curve. World Neurosurg 2021; 162:e1-e7. [PMID: 34785362 DOI: 10.1016/j.wneu.2021.11.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Minimally invasive transforaminal interbody fusion has become an increasingly common approach in adult degenerative spine disease but is associated with a steep learning curve. OBJECTIVE To evaluate the impact of the learning experience on mean procedure time and mean cost associated with each procedure. METHODS We studied the first one-hundred consecutive minimally invasive transforaminal interbody fusion procedures of a single surgeon. We performed multivariable linear regression models, modelling operating time and costs in function of the procedure order adjusted for patients' age, gender and number of surgical levels. The number of procedures necessary to attain proficiency was determined through a k-means cluster analysis. Finally, the total excess operative time and total excess cost until obtaining proficiency was evaluated. RESULTS Procedure order was found to impact procedure time and mean costs, with each successive case being associated with progressively less procedure time and cost. On average, each successive case was associated with a reduction in procedure time of 0.97 minutes (95% CI=0.54-1.40; p<0.001) and an average adjusted reduction in overall costs of $82.75 (95% CI=$35.93-129.57; p<0.001). An estimated 58 procedures were needed to attain proficiency, translating into an excess procedure time of 2604.2 minutes (average of 45 minutes per case), overall costs associated with the learning experience of $226,563.8 (average of $3974.80 per case), and excess surgical cost of $125,836.6 (average of $2207.66 per case). CONCLUSION Successive cases were associated with progressively less procedure time and mean overall and surgical costs, until a proficiency threshold was attained.
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16
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West JL, De Biase G, Bydon M, Bojaxhi E, Mendhi M, Quiñones-Hinojosa A, Abode-Iyamah K. What Is the Learning Curve for Lumbar Spine Surgery Under Spinal Anesthesia? World Neurosurg 2021; 158:e310-e316. [PMID: 34737101 DOI: 10.1016/j.wneu.2021.10.172] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Spinal anesthesia (SA) is routinely used in obstetrics and orthopedic surgery but has not been widely adopted in lumbar spine surgery (LSS). One perceived barrier is the learning curve for the neurosurgical and anesthesia team associated with managing a patient in the prone position under SA. METHODS A retrospective cohort of 34 LSS cases under SA at our institution was examined. Operative time, corrected operative time per level, and complications were analyzed. The learning curve was assessed using a curve-fit regression analysis. RESULTS Of patients, 62% were female, with mean (SD) age and body mass index of 60.7 (10.8) years and 29.9 (4.6) kg/m2, respectively. The mean (SD) for each time segment was operating room arrival to incision 35.7 (8.1) minutes, total surgical time 100.4 (35.8) minutes, and procedure finish to operating room exit 3.4 (2.5) minutes. When the times were normalized to procedure type and analyzed sequentially, the mean (SD) slope of all trendlines was 0.003 (0.005) with correlation coefficients of R2 = 0.0002-0.01, indicating no appreciable learning curve. Normalized postanesthesia care unit time was significantly shorter for overnight stay versus same-day discharge (0.64 vs. 1.36, P = 0.0005). CONCLUSIONS Our data demonstrate the lack of a learning curve when SA is implemented in LSS cases by an anesthetic team already familiar with SA techniques for other procedures. Importantly, the surgical team was already familiar with the minimally invasive surgery approaches used in conjunction with SA. This study highlights that the barriers to transitioning to SA for LSS may be fewer than perceived.
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Affiliation(s)
- James L West
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Gaetano De Biase
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elird Bojaxhi
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Marvesh Mendhi
- Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, USA
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17
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De Biase G, Gassie K, Garcia D, Abode-Iyamah K, Deen G, Nottmeier E, Chen S. Perioperative Comparison of Robotic-Assisted Versus Fluoroscopically Guided Minimally Invasive Transforaminal Lumbar Interbody Fusion. World Neurosurg 2021; 149:e570-e575. [PMID: 33549930 DOI: 10.1016/j.wneu.2021.01.133] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Robotic surgical systems have been developed to improve spine surgery accuracy. Studies have found significant reductions in screw revision rates and radiation exposure with robotic assistance compared with open surgery. The aim of the present study was to compare the perioperative outcomes between robot-assisted (RA) and fluoroscopically guided (FG) minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) performed by a single surgeon. METHODS The present retrospective cohort study analyzed all patients with lumbar degenerative disease who had undergone MI-TLIF by a single surgeon from July 2017 to March 2020. One group had undergone FG MI-TLIF and one group had undergone RA MI-TLIF. RESULTS Of the 101 patients included in the present study, 52 had undergone RA MI-TLIF and 49, FG MI-TLIF. We found no statistically significant differences in the operative time (RA, 241 ± 69.3 minutes; FG, 246.2 ± 56.3 minutes; P = 0.681). The mean radiation time for the RA group was 32.8 ± 28.8 seconds, and the mean fluoroscopy dose was 31.5 ± 30 mGy. The RA radiation exposure data were compared with similar data for the FG MI-TLIF group in a previous study (59.5 ± 60.4 mGy), with our patients' radiation exposure significantly lower (P = 0.035). The postoperative complications and rates of surgical revision were comparable. CONCLUSIONS Our results have demonstrated that RA MI-TLIF provides perioperative outcomes comparable to those with FG MI-TLIF. A reduced radiation dose to the patient was observed with RA compared with FG MI-TLIF. No differences were noted between the RA and FG cohorts in operative times, complication rates, revision rates, or length of stay.
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Affiliation(s)
- Gaetano De Biase
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Kelly Gassie
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Diogo Garcia
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Gordon Deen
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Eric Nottmeier
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Selby Chen
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.
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