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Hrabarchuk EI, Hannah T, Kalagara R, Li AY, Schupper AJ, McCarthy L, Ali M, Quinones A, Gometz A, Lovell M, Choudhri TF. Baseline ImPACT Composite Scores in Student-Athletes With Attention-Deficit/Hyperactivity Disorder. Arch Clin Neuropsychol 2024; 39:347-354. [PMID: 37824213 DOI: 10.1093/arclin/acad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Athletes who are diagnosed with attention-deficit/hyperactivity disorder (ADHD) are at increased risk of concussion compared to other athletes. Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is a widely used concussion tool, but it relies on pre-injury baseline testing that can be affected by psychiatric conditions. This research aims to determine if there are differences in pre-injury testing composite scores in student-athletes with ADHD compared to those without ADHD diagnosis. METHODS We obtained 11,563 pre-season ImPACT assessments of 7,454 student-athletes (ages: 12-22) from 2009 to 2019. After exclusions, there were 6,920 control and 276 ADHD subjects. Multivariable linear regression analyses compared the independent effect of ADHD on the six ImPACT composite score metrics with Bonferroni correction for multiple comparisons with a = 0.008. RESULTS Univariate analyses indicated ADHD is associated with more symptoms as measured by the Post-Concussion Symptom Scale (PCSS) (β = 2.67, 95% CI: 1.47-3.87, p < .0001) and worse Impulse Control scores (β = 0.93, 95% CI: 0.33-1.53, p = .002). In multivariate analysis, this association was the same for symptom score (β = 2.48, 95% CI: 1.22-3.74, p < .0001), but Impulse Control was not significantly different after multiple comparison adjustment (β = 0.87, 95% CI: 0.22-1.15, p = .009). CONCLUSIONS The ADHD subjects reported worse symptoms at baseline and had worse Impulse Control in univariate analysis, but not multivariate analysis. These results can further guide clinicians in concussion diagnosis and test interpretations for student-athletes with ADHD, considering the symptom burden at baseline.
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Affiliation(s)
- Eugene I Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Theodore Hannah
- Department of Neurosurgery, Lewis Katz School of Medicine Temple University, Philadelphia, PA, USA
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Adam Y Li
- Department of Neurosurgery, University of Rochester School of Medicine, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex Gometz
- Physical Medicine and Rehabilitation, Concussion Management of New York, NY, USA
| | - Mark Lovell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Karabacak M, Carr MT, Schupper AJ, Bhimani AD, Steinberger J, Margetis K. An Interpretable Machine Learning Approach to Predict Survival Outcomes in Spinal and Sacropelvic Chordomas. Spine (Phila Pa 1976) 2024:00007632-990000000-00638. [PMID: 38605635 DOI: 10.1097/brs.0000000000005002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 01/30/2024] [Accepted: 03/20/2024] [Indexed: 04/13/2024]
Abstract
STUDY DESIGN Retrospective, population-based cohort study. OBJECTIVE This study aimed to develop machine learning (ML) models to predict five-year and 10-year mortality in spinal and sacropelvic chordoma patients and integrate them into a web application for enhanced prognostication. SUMMARY OF BACKGROUND DATA Past research has uncovered factors influencing survival in spinal chordoma patients. While identifying individual predictors is important, personalized survival predictions are equally vital. Though prior efforts have resulted in nomograms aiming to serve this purpose, they cannot capture complex interactions within data and rely on statistical assumptions that may not fit real-world data. METHODS Adult spinal and sacropelvic chordoma patients were identified from the National Cancer Database. Sociodemographic, clinicopathologic, diagnostic, and treatment-related variables were utilized as predictive features. Five supervised ML algorithms (TabPFN, CatBoost, XGBoost, LightGBM, and Random Forest) were implemented to predict mortality at five and 10 years postdiagnosis. Model performance was primarily evaluated using the area under the receiver operating characteristic (AUROC). SHapley Additive exPlanations (SHAP) values and partial dependence plots provided feature importance and interpretability. The top models were integrated into a web application. RESULTS From the NCDB, 1206 adult patients diagnosed with histologically confirmed spinal and sacropelvic chordomas were retrieved for the five-year mortality outcome [423 (35.1%) with five-year mortality] and 801 patients for the 10-year mortality outcome [588 (73.4%) with 10-year mortality]. Top-performing models for both of the outcomes were the models created with the CatBoost algorithm. The CatBoost model for five-year mortality predictions displayed a mean AUROC of 0.801, and the CatBoost model predicting 10-year mortality yielded a mean AUROC of 0.814. CONCLUSIONS This study developed ML models that can accurately predict five-year to 10-year survival probabilities in spinal chordoma patients. Integrating these interpretable, personalized prognostic models into a web application provides quantitative survival estimates for a given patient. The local interpretability enables transparency into how predictions are influenced. Further external validation is warranted to support generalizability and clinical utility.
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Affiliation(s)
- Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, New York, NY
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3
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Ong V, Schupper AJ, Bederson JB, Choudhri TF, Shrivastava RK. Bibliometric Analysis of the Top 100 Cited Articles and Author H-Indexes on the Surgical Treatment of Trigeminal Neuralgia. World Neurosurg 2024; 184:44-62. [PMID: 38216034 DOI: 10.1016/j.wneu.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/07/2024] [Indexed: 01/14/2024]
Abstract
INTRODUCTION Medically refractory cases of trigeminal neuralgia often require treatment escalation. Surgical options include microvascular decompression and percutaneous ablation. This paper provides a bibliometric analysis of the most influential articles on the surgical management of trigeminal neuralgia. METHODS The Web of Science database was queried to identify the top 100 cited articles concerning surgical treatment of trigeminal neuralgia. The search terms used included ALL=(("trigeminal neuralgia" OR "tic douloureux" OR "Fothergill's disease" OR "Trifacial neuralgia") AND ("surgical treatment" OR "surgical management" OR "surgery" OR "neurosurgery") NOT ("radiosurgery" OR "gamma knife")). The extracted variables included the first and senior author names, journal, publication year, institution, and surgical modality. RESULTS Our bibliometric search yielded 2104 studies, with 41,502 citations overall. Within the top 100 articles, Zakrzewska had the most first author papers (n = 5), and Burchiel had the most senior author papers (n = 6). The Massachusetts General Hospital was the most represented institution (n = 5). The United States was the most represented country (51%). Microvascular decompression was the most studied surgical strategy (51%), followed by percutaneous radiofrequency coagulation (9%), balloon/nerve compression (7%), and glycerol rhizolysis (7%). Some studies assessed multiple treatment modalities (22%). The types of studies included retrospective articles (58%), prospective articles (26%), reviews (10%), anatomic studies (2%), and basic science (1%). Neurosurgery (35%) and the Journal of Neurosurgery (33%) were the most represented journals. CONCLUSIONS The current literature consists of retrospective reviews and mostly describes microvascular decompression for trigeminal neuralgia. Future studies should include further characterization of other surgical modalities such as percutaneous radiofrequency thermocoagulation, glycerol injection, and balloon compression.
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Affiliation(s)
- Vera Ong
- John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Raj K Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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4
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Karabacak M, Schupper AJ, Carr MT, Hickman ZL, Margetis K. From Text to Insight: A Natural Language Processing-Based Analysis of Topics and Trends in Neurosurgery. Neurosurgery 2024; 94:679-689. [PMID: 37988054 DOI: 10.1227/neu.0000000000002763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Neurosurgical research is a rapidly evolving field, with new research topics emerging continually. To provide a clearer understanding of the evolving research landscape, our study aimed to identify and analyze the prevalent research topics and trends in Neurosurgery. METHODS We used BERTopic, an advanced natural language processing-based topic modeling approach, to analyze papers published in the journal Neurosurgery . Using this method, topics were identified based on unique sets of keywords that encapsulated the core themes of each article. Linear regression models were then trained on the topic probabilities to identify trends over time, allowing us to identify "hot" (growing in prominence) and "cold" (decreasing in prominence) topics. We also performed a focused analysis of the trends in the current decade. RESULTS Our analysis led to the categorization of 12 438 documents into 49 distinct topics. The topics covered a wide range of themes, with the most commonly identified topics being "Spinal Neurosurgery" and "Treatment of Cerebral Ischemia." The hottest topics of the current decade were "Peripheral Nerve Surgery," "Unruptured Aneurysms," and "Endovascular Treatments" while the cold topics were "Chiari Malformations," "Thromboembolism Prophylaxis," and "Infections." CONCLUSION Our study underscores the dynamic nature of neurosurgical research and the evolving focus of the field. The insights derived from the analysis can guide future research directions, inform policy decisions, and identify emerging areas of interest. The use of natural language processing in synthesizing and analyzing large volumes of academic literature demonstrates the potential of advanced analytical techniques in understanding the research landscape, paving the way for similar analyses across other medical disciplines.
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Affiliation(s)
- Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, New York , New York , USA
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5
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Schupper AJ, Patel S, Steinberger JM, Germano IM. The role of minimally invasive surgery within a multidisciplinary approach for patients with metastatic spine disease over a decade: A systematic review. Neuro Oncol 2024; 26:417-428. [PMID: 37988270 PMCID: PMC10912012 DOI: 10.1093/neuonc/noad206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Metastatic spine disease (MSD) occurs commonly in cancer patients causing pain, spinal instability, devastating neurological compromise, and decreased quality of life. Oncological patients are often medically complex and frail, precluding them form invasive procedures. To address this issue, minimally invasive spinal surgery (MISS) techniques are desirable. The aim of this study is to review published peer-reviewed literature and ongoing clinical trials to provide current state of the art. METHODS A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, assessing MISS in MSD patients for the period 2013-2023. Innovations under development were assessed by querying and reviewing data from currently enrolling U.S. registered clinical trials. RESULTS From 3,696 articles, 50 studies on 3,196 patients focused on spinal oncology MISS. The most commonly reported techniques were vertebral augmentation (VA), percutaneous spinal instrumentation, and radiofrequency ablation (RFA). Surgical instrumentation/stabilization techniques were reported in 10/50 articles for a total of 410 patients. The majority of studies focused on pain as a primary outcome measure, with 28/50 studies reporting a significant improvement in pain following intervention. In the United States, 13 therapeutic trials are currently recruiting MSD patients. Their main focus includes radiosurgery, VA and/or RFA, and laser interstitial thermal therapy. CONCLUSIONS Due to their medical complexity and increased fragility, MSD patients may benefit from minimally invasive approaches. These strategies are effective at mitigating pain and preventing neurological deterioration, while providing other advantages including ease to start/resume systemic/radiotherapy treatment(s).
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shrey Patel
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeremy M Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Isabelle M Germano
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Kalagara R, Asfaw ZK, Carr M, Quinones A, Downes MH, Vasan V, Li T, McCarthy L, Hrabarchuk EI, Genadry L, Schupper AJ, DeMaria S, Gal JS, Choudhri TF. Clinical Considerations and Outcomes for Spine Surgery Patients with a History of Transplant: A Systematic Scoping Review. World Neurosurg 2024; 183:94-105. [PMID: 38123131 DOI: 10.1016/j.wneu.2023.12.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 12/12/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the perioperative management and outcomes of patients with a prior history of successful transplantation undergoing spine surgery. METHODS We searched Medline, Embase, and Cochrane Central Register of Controlled Trials for matching reports in July 2021. We included case reports, cohort studies, and retrospective analyses, including terms for various transplant types and an exhaustive list of key words for various forms of spine surgery. RESULTS We included 45 studies consisting of 34 case reports (published 1982-2021), 3 cohort analyses (published 2005-2006), and 8 retrospective analyses (published 2006-2020). The total number of patients included in the case reports, cohort studies, and retrospective analysis was 35, 48, and 9695, respectively. The mean 1-year mortality rate from retrospective analyses was 4.6% ± 1.93%, while the prevalence of perioperative complications was 24%. Cohort studies demonstrated an 8.5% ± 12.03% 30-day readmission rate. The most common procedure performed was laminectomy (38.9%) among the case reports. Mortality after spine surgery was noted for 4 of 35 case report patients (11.4%). CONCLUSIONS This is the first systematic scoping review examining the population of transplant patients with subsequent unrelated spine surgery. There is significant heterogeneity in the outcomes of post-transplant spine surgery patients. Given the inherent complexity of managing this group and elevated mortality and complications compared to the general spine surgery population, further investigation into their clinical care is warranted.
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Affiliation(s)
- Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Zerubabbel K Asfaw
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Carr
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Troy Li
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eugene I Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lisa Genadry
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samuel DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan S Gal
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lamb CD, Schupper AJ, Quinones A, Zhang JY, Steinberger J, Margetis K. Cervical Spine Stenosis Causing Diaphragmatic Paralysis: A Case Study and Narrative Review of Clinical Presentations and Outcomes. Clin Spine Surg 2024:01933606-990000000-00270. [PMID: 38419161 DOI: 10.1097/bsd.0000000000001588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 07/03/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024]
Abstract
STUDY DESIGN Case report and narrative review. OBJECTIVE To explore the therapeutic role of surgical and nonsurgical treatment of diaphragmatic paralysis secondary to spinal cord and nerve root compression. SUMMARY OF BACKGROUND DATA Phrenic nerve dysfunction due to central or neuroforaminal stenosis is a rare yet unappreciated etiology of diaphragmatic paralysis and chronic dyspnea. Surgical spine decompression, diaphragmatic pacing, and intensive physiotherapy are potential treatment options with varying degrees of evidence. METHODS The case of a 70-year-old male with progressive dyspnea, reduced hemi-diaphragmatic excursion, and C3-C7 stenosis, who underwent a microscopic foraminotomy is discussed. Literature review (MEDLINE, PubMed, Google Scholar) identified 19 similar reports and discussed alternative treatments and outcomes. RESULTS AND CONCLUSIONS Phrenic nerve root decompression and improvement in neuromonitoring signals were observed intraoperatively. The patient's postoperative course was uncomplicated, and after 15 months, he experienced significant symptomatic improvement and minor improvement in hemi-diaphragmatic paralysis and pulmonary function tests. All case reports of patients treated with spinal decompression showed symptomatic and/or functional improvement, while one of the 2 patients treated with physiotherapy showed improvement. More studies are needed to further describe the course and outcomes of these interventions, but early identification and spinal decompression can be an effective treatment. OCEBM LEVEL OF EVIDENCE Level-4.
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Affiliation(s)
- Colin D Lamb
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY
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Devarajan A, Vasan V, Dullea JT, Zhang JY, Vasa D, Schupper AJ, Nichols N, Ranti D, McCarthy L, Rao M, Sudhir S, Cho L, Rutland JW, Post KD, Bederson J, Shrivastava RK. Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection. Neurosurgery 2024:00006123-990000000-01072. [PMID: 38421190 DOI: 10.1227/neu.0000000000002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 01/04/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA. METHODS Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ2-tests and student t-tests. For those factors with a P-value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors. RESULTS A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak (P < .01), postoperative diabetes insipidus (DI) (P < .01), increased surgery duration (P = .01), and elevated maximal tumor dimension (P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression. CONCLUSION Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.
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Affiliation(s)
- Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Stein AA, Samdani AF, Schupper AJ, Naseer Z, Shah RV, Zeller S, Pahys JM, Samuel SP, Quinonez A, Hwang SW. Lumbar Vertebral Body Tethering: Single Center Outcomes and Reoperations in a Consecutive Series of 106 Patients. Spine (Phila Pa 1976) 2024:00007632-990000000-00599. [PMID: 38375615 DOI: 10.1097/brs.0000000000004967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 11/28/2023] [Accepted: 02/10/2024] [Indexed: 02/21/2024]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To evaluate the outcomes and reoperation rates in patients with adolescent idiopathic scoliosis (AIS) undergoing lumbar anterior vertebral body tethering (AVBT). SUMMARY OF BACKGROUND DATA Anterior vertebral body tethering (AVBT) is a viable option in growing children. The benefit of motion preservation must be balanced by a higher reoperation rate. A paucity of reports has addressed lumbar AVBT. METHODS A single-center retrospective study was conducted to identify all patients who underwent lumbar AVBT (lowest instrumented vertebra L3 or L4) with a minimum 2 years of follow-up. Clinical and radiographic parameters, including complications and reoperations, were also collected. Statistical analysis was performed using Student's t-test for qualitative variables. RESULTS From a dataset of 551 patients, we identified 106 patients (89% female) who underwent a lumbar AVBT (33 lumbar only, 73 bilateral thoracic/lumbar) with mean follow-up of 4.1±1.6 years at which point 85% (90/106) had reached skeletal maturity. Preoperatively, these patients were skeletally immature (age: 12.8±1.3 y, Sanders: 3.3±0.8, R=0.6±0.9) with a lumbar coronal curve angle of 49.6°±11.2 which corrected to 19.9°±11.2 (P <0.0001) at most recent follow-up. At the latest follow-up, 76.4% (81/106) of the patients harbored a coronal curve angle of < 30°. Twenty patients (18.9%) underwent 23 reoperations, with overcorrection being the most common (10/23, 43%). Broken tethers led to reoperation in 3 instances (3/23, 13%). Six patients in the cohort needed a posterior spinal fusion (6/106, 5.4%). CONCLUSIONS Vertebral body tethering is a viable treatment option for skeletally immature patients with idiopathic scoliosis. This report is the largest to date for lumbar AVBT, highlighting that 84% of patients harbored a curve < 35° at the latest follow-up but with an 18.9% reoperation rate. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Alan A Stein
- Department of Neurosurgery, Shriners Children's - Philadelphia, PA, USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY, USA
| | - Amer F Samdani
- Department of Neurosurgery, Shriners Children's - Philadelphia, PA, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Shriners Children's - Philadelphia, PA, USA
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zan Naseer
- Department of Neurosurgery, Shriners Children's - Philadelphia, PA, USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY, USA
| | - Ronit V Shah
- Department of Orthopaedic Surgery, Temple University Hospital, Philadelphia, PA, USA
| | - Sabrina Zeller
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY, USA
| | - Joshua M Pahys
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | | | - Alejandro Quinonez
- Department of Orthopaedic Surgery, Shriners Children's - Philadelphia, PA, USA
| | - Steven W Hwang
- Department of Neurosurgery, Shriners Children's - Philadelphia, PA, USA
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10
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Karabacak M, Schupper AJ, Carr MT, Bhimani AD, Steinberger J, Margetis K. Development and internal validation of machine learning models for personalized survival predictions in spinal cord glioma patients. Spine J 2024:S1529-9430(24)00072-X. [PMID: 38365005 DOI: 10.1016/j.spinee.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 09/14/2023] [Revised: 01/16/2024] [Accepted: 02/05/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND CONTEXT Numerous factors have been associated with the survival outcomes in patients with spinal cord gliomas (SCG). Recognizing these specific determinants is crucial, yet it is also vital to establish a reliable and precise prognostic model for estimating individual survival outcomes. OBJECTIVE The objectives of this study are twofold: first, to create an array of interpretable machine learning (ML) models developed for predicting survival outcomes among SCG patients; and second, to integrate these models into an easily navigable online calculator to showcase their prospective clinical applicability. STUDY DESIGN This was a retrospective, population-based cohort study aiming to predict the outcomes of interest, which were binary categorical variables, in SCG patients with ML models. PATIENT SAMPLE The National Cancer Database (NCDB) was utilized to identify adults aged 18 years or older who were diagnosed with histologically confirmed SCGs between 2010 and 2019. OUTCOME MEASURES The outcomes of interest were survival outcomes at three specific time points post-diagnosis: 1, 3, and 5 years. These outcomes were formed by combining the "Vital Status" and "Last Contact or Death (Months from Diagnosis)" variables. Model performance was evaluated visually and numerically. The visual evaluation utilized receiver operating characteristic (ROC) curves, precision-recall curves (PRCs), and calibration curves. The numerical evaluation involved metrics such as sensitivity, specificity, accuracy, area under the PRC (AUPRC), area under the ROC curve (AUROC), and Brier Score. METHODS We employed five ML algorithms-TabPFN, CatBoost, XGBoost, LightGBM, and Random Forest-along with the Optuna library for hyperparameter optimization. The models that yielded the highest AUROC values were chosen for integration into the online calculator. To enhance the explicability of our models, we utilized SHapley Additive exPlanations (SHAP) for assessing the relative significance of predictor variables and incorporated partial dependence plots (PDPs) to delineate the influence of singular variables on the predictions made by the top performing models. RESULTS For the 1-year survival analysis, 4,913 patients [5.6% with 1-year mortality]; for the 3-year survival analysis, 4,027 patients (11.5% with 3-year mortality]; and for the 5-year survival analysis, 2,854 patients (20.4% with 5-year mortality) were included. The top models achieved AUROCs of 0.938 for 1-year mortality (TabPFN), 0.907 for 3-year mortality (LightGBM), and 0.902 for 5-year mortality (Random Forest). Global SHAP analyses across survival outcomes at different time points identified histology, tumor grade, age, surgery, radiotherapy, and tumor size as the most significant predictor variables for the top-performing models. CONCLUSIONS This study demonstrates ML techniques can develop highly accurate prognostic models for SCG patients with excellent discriminatory ability. The interactive online calculator provides a tool for assessment by physicians (https://huggingface.co/spaces/MSHS-Neurosurgery-Research/NCDB-SCG). Local interpretability informs prediction influences for a given individual. External validation across diverse datasets could further substantiate potential utility and generalizability. This robust, interpretable methodology aligns with the goals of precision medicine, establishing a foundation for continued research leveraging ML's predictive power to enhance patient counseling.
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Affiliation(s)
- Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Ave, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Ave, New York, NY, USA
| | - Matthew T Carr
- Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Ave, New York, NY, USA
| | - Abhiraj D Bhimani
- Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Ave, New York, NY, USA
| | - Jeremy Steinberger
- Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Ave, New York, NY, USA
| | - Konstantinos Margetis
- Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Ave, New York, NY, USA.
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Kalagara R, Hrabarchuk EI, Hannah TC, Downes MH, Li T, Vasan V, Li AY, Asfaw ZK, Quinones A, McCarthy L, Schupper AJ, Gometz A, Lovell MR, Choudhri TF. The effect of age on baseline neurocognitive performance. Brain Inj 2024; 38:136-141. [PMID: 38328998 DOI: 10.1080/02699052.2024.2307968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 01/17/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVE Evaluate the independent effect of age on baseline neurocognitive performance. STUDY DESIGN Baseline ImPACT scores from tests taken by 7454 athletes aged 12-22 from 2009 to 2019 were split into three age cohorts: 12-14 years (3244), 15-17 years (3732), and 18-22 years (477). Linear regression analyses were used to evaluate the effect of age on ImPACT composite scores while controlling for demographic differences, medication-use, and symptom burden. Significance values have been set at p < 0.05. RESULTS Linear regression analyses demonstrated that increased age does not significantly affect symptom score (β = 0.06, p = 0.54) but does improve impulse control (β = -0.45, p < 0.0001), verbal memory (β = 0.23, p = 0.03), visualmotor (β = 0.77, p < 0.0001), and reaction time (β = -0.008, p < 0.0001) scores. However, age did not have an effect on visual memory scores (β = -0.25, p = 0.07). CONCLUSIONS Age was shown to be an independent modifier of impulse control, verbal memory, visual motor, and reaction time scores but not visual memory or symptom scores. This underscores the previous literature showing developmental differences as age increases among the adolescent athlete population. This data also indicates the need for repeat neurocognitive baseline testing every other year as baseline scoring is likely to change as athletes become older.
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Affiliation(s)
- Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Eugene I Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Theodore C Hannah
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Troy Li
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Adam Y Li
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Zerubabbel K Asfaw
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
| | - Alex Gometz
- Concussion Management of New York, New York, USA
| | - Mark R Lovell
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine, at Mount Sinai, New York, USA
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Rodriguez B, Campbell P, Borrello J, Odland I, Williams T, Hrabarchuk EI, Young T, Sharma A, Schupper AJ, Rapoport B, Ivkov R, Hadjipanayis C. A Novel Port to Facilitate Magnetic Hyperthermia Therapy for Glioma. J Biomech Eng 2024; 146:011009. [PMID: 37773642 DOI: 10.1115/1.4063556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Abstract
High-grade gliomas (HGG) are the most common primary brain malignancy and continue to be associated with a dismal prognosis (median survival rate of 15-18 months) with standard of care therapy. Magnetic hyperthermia therapy (MHT) is an emerging intervention that leverages the ferromagnetic properties of magnetic iron-oxide nanoparticles (MIONPs) to target cancer cells that are otherwise left behind after resection. We report a novel port device to facilitate localization, delivery, and temperature measurement of MIONPs within a target lesion for MHT therapy. We conducted an in-depth literature and intellectual property review to define specifications of the conceived port device. After setting the design parameters, a thorough collaboration with neurological surgeons guided the iterative modeling process. A prototype was developed using Fusion 360 (Autodesk, San Rafael, CA) and printed on a Form 3 printer (Formlabs, Medford, MA) in Durable resin. The prototype was then tested in a phantom skull printed on a Pro-Jet 660Pro 3D printer (3D Systems, Rock Hill, SC) and a brain model based on mechanical and electrochemical properties of native brain tissue. This phantom underwent MHT heating tests using an alternating magnetic field (AMF) sequence based on current MHT workflow. Successful localization, delivery, and temperature measurement were demonstrated. The purpose of this study was twofold: first, to create and validate the procedural framework for a novel device, providing the groundwork for an upcoming comprehensive animal trial and second, to elucidate a cooperative approach between engineers and clinicians that propels advancements in medical innovation.
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Affiliation(s)
- Benjamin Rodriguez
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Peter Campbell
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Joseph Borrello
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Ian Odland
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Tyree Williams
- Department of Biomedical Engineering, Rensselaer Polytechnic Institute, 110 8th St, Troy, NY 12180; Department of Neurosurgery,Sinai BioDesign,Mount Sinai, New York, NY 10029
| | - Eugene I Hrabarchuk
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Tirone Young
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Anirudh Sharma
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD 21218
| | | | - Benjamin Rapoport
- Icahn School of Medicine at Mount Sinai, New York, NY 10029; Department of Neurosurgery, Sinai BioDesign, Mount Sinai, New York, NY 10029
| | - Robert Ivkov
- Department of Radiation Oncology and Molecular Radiation Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD 21218; Department of Oncology, Sydney Kimmel Comprehensive Cancer Center, School of Medicine, Johns Hopkins University, Baltimore, MD 21218; Department of Mechanical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD 21218;Department of Materials Science and Engineering, Whiting School of Engineering, Johns Hopkins UniversityBaltimore, MD 21218
| | - Constantinos Hadjipanayis
- Department of Neurological Surgery, Center for Image-Guided Neurosurgery, School of Medicine, University of Pittsburgh, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213
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Carrasquilla A, Zgurov A, Salih M, Le C, Matsoukas S, Feng R, Schupper AJ, Hadjipanayis C. Exoscopic resection of a parasagittal atypical meningioma. Neurosurg Focus Video 2024; 10:V8. [PMID: 38283808 PMCID: PMC10821652 DOI: 10.3171/2023.10.focvid23164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 10/20/2023] [Indexed: 01/30/2024]
Abstract
This video demonstrates use of the Synaptive 3D exoscope to enhance complex meningioma resection. The patient was a 58-year-old female who presented with new-onset seizures. Workup revealed a parasagittal meningioma over the bilateral cortices. She was started on 750 mg of Keppra twice daily and tapered dexamethasone and discharged. MR venography demonstrated segmental occlusion of the superior sagittal sinus. She then underwent a diagnostic angiogram and tumor Onyx embolization of the bilateral middle meningeal artery feeders. She then underwent a craniotomy for meningioma resection using 3D exoscope guidance. She awoke with a stable examination in the intensive care unit and worked with physical therapy on postoperative day 1. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23164.
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Affiliation(s)
- Alejandro Carrasquilla
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Artur Zgurov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Mira Salih
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Chi Le
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Rui Feng
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
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Abbasi HR, Abd-Elsayed A, Aiyer R, Budwany R, Engle A, Hussain N, Kodsy M, Naji M, Navalgund YA, Patel AM, Robinson C, Schupper AJ, Speer J, Steinberger JM, Storlie NR, Tanios M. Contributors. Decompressive Techniques 2024:vi-vii. [DOI: 10.1016/b978-0-323-87751-0.00004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Ali M, Smith C, Vasan V, Downes M, Schuldt BR, Odland I, Murtaza-Ali M, Dullea J, Rossitto CP, Schupper AJ, Hardigan T, Asghar N, Liang J, Mocco J, Kellner CP. Characterization of length of stay after minimally invasive endoscopic intracerebral hemorrhage evacuation. J Neurointerv Surg 2023; 16:15-23. [PMID: 36882321 DOI: 10.1136/jnis-2023-020152] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/23/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) post-evacuation is often long and costly. OBJECTIVE To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation. METHODS Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively. RESULTS Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4-15) days and 16 (9-27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6-month mRS outcomes (5 (4-6) vs 3 (2-4), P<0.0001). CONCLUSIONS We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Murtaza-Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Lee J, Schupper AJ, Okewunmi J, Bronson WH, Steinberger JM, Lenke LG, Lin JD. The iliac kickstand screw: anatomic CT analysis of screw trajectory and osseous corridor for screw placement. Br J Neurosurg 2023:1-5. [PMID: 38050370 DOI: 10.1080/02688697.2023.2288590] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/08/2022] [Accepted: 11/08/2023] [Indexed: 12/06/2023]
Abstract
INTRODUCTION The 'kickstand screw-rod' technique has been recently described for correction of coronal malalignment. This technique utilizes powerful 'construct-to-ilium' distraction between a fixed multi-screw thoracic construct and the ilium, facilitated by a novel 'iliac kickstand screw'. The 'iliac kickstand screw' traverses a previously undescribed osseous corridor in the ilium. OBJECTIVE Using a radiographic CT study, the objective is to describe a large osseous corridor within the ilium to accommodate the novel iliac kickstand screw. METHODS 50 consecutive patients with pelvic CTs at an academic medical center were queried. Simulated iliac kickstand screw trajectories for the left and right hemipelvis were analyzed with 3D visualization software. Maximal screw lengths and dimensions, and trajectories in the osseous corridor were measured. RESULTS 50 patients' (31 female, 19 male) pelvic CTs were measured with a total of 100 simulated screws. The mean age was 52.4 years and BMI 28.1 ± 7.9. The average length is 119.7 ± 6.6 mm (range 98.7 - 135.3). The narrowest width (maximum potential screw diameter) is 17.8 ± 2.9 mm (coronal) and 20.8 ± 5.3 mm (sagittal). The starting point to the top of the iliac crest is 66.4 mm lateral to midline, and 15.9° caudal in the sagittal and 6.1° lateral in the coronal planes. CONCLUSIONS The novel iliac kickstand screw traverses a consistent and large osseous corridor within the ilium. The average simulated screw length is 119.7 mm and maximum potential diameter of 17.8 mm. Starting points relative to the iliac crest are identified.
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Affiliation(s)
- Jonathan Lee
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | - Jeffrey Okewunmi
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Wesley H Bronson
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA
| | | | - Lawrence G Lenke
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - James D Lin
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA
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Waterkeyn F, Ikwuegbuenyi CA, Woodfield J, Sommer F, Magogo J, Cheserem B, Schupper AJ, Shabani HK, Hussain I, Ahmad AA, Balsano M, Mangat H, Härtl R. Evaluating the Feasibility and Outcomes of a Scoliosis Surgical Camp in a Resource-Limited Setting in Sub-Saharan Africa. World Neurosurg 2023; 180:e550-e559. [PMID: 37778623 DOI: 10.1016/j.wneu.2023.09.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND In sub-Saharan Africa, the estimated prevalence of scoliosis ranges from 3.3% to 5.5%. The management of these deformities is restricted due to lack of infrastructure and access to deformity spine surgeons. Utilizing surgical camps has been demonstrated to be efficient in transferring skills to low-resource environments; however, this has not been documented concerning deformity surgery. METHODS We conducted a cross-sectional study. The scoliosis camp was held at a major referral spine center in East Africa. We documented information about the organization of the course. We also collected clinical and demographic patient data. Finally, we assessed the knowledge and confidence among surgeon participants on the management scoliosis. RESULTS The camp lasted 5 days and consisted of lectures and case discussions, followed by casting and surgical sessions. Five patients were operated during the camp. All the patients in the study were diagnosed with AIS, except one with a congenital deformity. The primary curve in the spine was in the thoracic region for all patients. Six months postoperative Scoliosis Research Society-22R Scoring System (SRS-22R) score ranged from 3.3-4.5/5. 87.5% of the participants found the course content satisfactory. CONCLUSIONS To the best of our knowledge, this is the first time an African scoliosis camp has been established. The study highlights the difficulty of conducting such a course and illustrates the feasibility of executing these complex surgeries in a resource-limited environment.
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Affiliation(s)
- François Waterkeyn
- Department of Neurosurgery, Weill Cornell Medicine, New-York Presbyterian, Och Spine, New York, New York, USA; Department of Neurosciences, Grand Hôpital de Charleroi, Charleroi, Belgium.
| | - Chibuikem A Ikwuegbuenyi
- Department of Neurosurgery, Weill Cornell Medicine, New-York Presbyterian, Och Spine, New York, New York, USA; Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salam, Tanzania
| | - Julie Woodfield
- Department of Neurosurgery, Weill Cornell Medicine, New-York Presbyterian, Och Spine, New York, New York, USA; Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salam, Tanzania
| | - Fabian Sommer
- Department of Neurosurgery, Weill Cornell Medicine, New-York Presbyterian, Och Spine, New York, New York, USA
| | - Juma Magogo
- Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salam, Tanzania
| | - Beverly Cheserem
- Department of Neurological Surgery, Aga Khan University Hospital, Nairobi, Kenya
| | - Alexander J Schupper
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hamisi K Shabani
- Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salam, Tanzania
| | - Ibrahim Hussain
- Department of Neurosurgery, Weill Cornell Medicine, New-York Presbyterian, Och Spine, New York, New York, USA
| | - Alaaeldin Azmi Ahmad
- Pediatric Orthopedic Surgery, Palestine Polytechnic University, Ramallah, Palestine
| | - Massimo Balsano
- Regional Spinal Department, UOC Ortopedia A, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Halinder Mangat
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Medicine, New-York Presbyterian, Och Spine, New York, New York, USA; Division of Neurosurgery, Muhimbili Orthopedic and Neurosurgery Institute, Dar es Salam, Tanzania
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Yuk FJ, Carr MT, Schupper AJ, Lin J, Tadros R, Wiklund P, Sfakianos J, Steinberger J. Da Vinci Meets Globus Excelsius GPS: A Totally Robotic Minimally Invasive Anterior and Posterior Lumbar Fusion. World Neurosurg 2023; 180:29-35. [PMID: 37708971 DOI: 10.1016/j.wneu.2023.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/05/2023] [Accepted: 09/07/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Minimally invasive approaches to the spine via anterior and posterior approaches have been increasing in popularity, culminating in the development of robot-assisted spinal fusions. The da Vinci surgical robot has been used for anterior lumbar interbody fusion (ALIF), with promising results. Similarly, multiple spinal robots have been developed to assist placement of posterior pedicle screws. However, no previous cases have reported on using robots for both anterior and posterior fixation in a single surgery. We present a technical note on the first reported case of a totally robotic minimally invasive anterior and posterior lumbar fusion and instrumentation. METHODS A 65-year-old man with chronic low back pain and left greater than right lower extremity radiculopathy was found to have grade 1 spondylolisthesis at L5/S1 that worsened on standing upright. He underwent ALIF using a da Vinci robotic approach, followed by percutaneous posterior instrumented fusion with the Globus Excelsius GPS robot. RESULTS The patient did well postoperatively, with improvement of back and leg pain at 3 months follow-up. Radiography confirmed appropriate placement of the interbody cage and pedicle screws. CONCLUSIONS All-robotic placement of both ALIF and posterior lumbar pedicle fixation may be safe, feasible, and efficacious.
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Affiliation(s)
- Frank J Yuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew T Carr
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Lin
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rami Tadros
- Department of Vascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jeremy Steinberger
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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19
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Schupper AJ, Hadjipanayis CG. In Reply to the Letter to the Editor Regarding "Improving Surgeon Well-Being: Ergonomics in Neurosurgery". World Neurosurg 2023; 179:253. [PMID: 38078396 DOI: 10.1016/j.wneu.2023.08.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 08/28/2023] [Indexed: 12/18/2023]
Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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20
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Schupper AJ, Boylan AJ, Houten JK. Is Cervical Disk Arthroplasty a Suitable Alternative to Treat Degenerative Cervical Myelopathy? Clin Spine Surg 2023; 36:356-362. [PMID: 37684716 DOI: 10.1097/bsd.0000000000001528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/10/2023] [Indexed: 09/10/2023]
Abstract
STUDY DESIGN Systemic review. OBJECTIVE To understand the role of cervical disk arthroplasty in the treatment of cervical myelopathy. SUMMARY OF BACKGROUND DATA The surgical management of degenerative cervical myelopathy (DCM) most frequently involves decompression and fusion, but stiffness introduced by the fusion and adjacent segment degeneration remain problems that can result in significant morbidity. Cervical disk arthroplasty (CDA) is a newer procedure that has been demonstrated to be safe and effective for the management of cervical spine degenerative disk disease, but it has not been traditionally considered as a treatment option for DCM and the use for this indication has not been extensively studied. MATERIALS AND METHODS A systematic review was undertaken using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using a search strategy to query all relevant articles on the use of cervical disk arthroplasty in the setting of cervical myelopathy over a 20-year period (2004-2023). This review examines the literature to assess our current understanding of the appropriateness, safety, and value of CDA in the treatment of DCM. RESULTS A total of 844 patients received CDA across the 14 studies that met inclusion criteria, with an average of 60.3±40.4 patients per study (range: 11-152 subjects). Featured studies included 5 (35.7%) prospective studies, of which 2 were randomized. All studies had primary outcome measures of disability and/or pain scores, with the Japanese Orthopedic Association myelopathy score and neck disability index as the most commonly assessed. Four (26.7%) studies compared arthroplasty with arthrodesis. Safety of CDA for DCM was found in all studies with improvement in clinical outcome measurements. CONCLUSION Cervical disk arthroplasty appears to be a safe and effective surgical option in the management of degenerative cervical myelopathy. Further study is needed to assess if arthroplasty provides clinical improvement in DCM of comparable magnitude and durability as traditional fusion strategies.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY
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21
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Ali M, Maragkos GA, Yaeger KA, Schupper AJ, Hardigan TA, Vasan V, Schuldt BR, Odland IC, Downes M, Dullea J, Ascanio LC, Troiani ZS, Mohammadi N, Lara-Reyna J, Rothrock RJ, Lefton DR, Mocco J, Kellner CP. Initial experience with minimally invasive endoscopic evacuation of intracerebral hemorrhage in the setting of radiographic herniation. J Stroke Cerebrovasc Dis 2023; 32:107309. [PMID: 37625345 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (ICH) can rapidly result in cerebral herniation, leading to poor neurologic outcomes or mortality. To date, neither decompressive hemicraniectomy (DH) nor hematoma evacuation have been conclusively shown to improve outcomes for comatose ICH patients presenting with cerebral herniation, with these patients largely excluded from clinical trials. Here we present the outcomes of a series of patients presenting with ICH and radiographic herniation who underwent emergent minimally invasive (MIS) ICH evacuation. METHODS We reviewed our prospectively collected registry of patients undergoing MIS ICH evacuation at a single institution from 01/01/2017 to 10/01/2021. We selected all consecutive patients with Glasgow coma scale (GCS) ≤ 8 and radiographic herniation for this case series. Clinical and radiographic variables were collected, including admission GCS score, preoperative and postoperative hematoma volumes, National Institute of Health stroke scale (NIHSS) scores, and modified Rankin scale (mRS) scores at last follow-up. RESULTS Of 176 patients with spontaneous supratentorial ICH who underwent minimally invasive endoscopic evacuation during the study time period, a total of 9 patients presented with GCS ≤ 8 and evidence of radiographic herniation. Among these patients, the mean age was 62 ± 12 years, the median GCS at presentation was 5 [IQR 4-6], the mean preoperative hematoma volume was 94 ± 44 mL, the mean time from ictus to evacuation was 12 ± 5 h, and the mean postoperative hematoma volume was 11 ± 16 mL, for a median evacuation percentage of 97% [83-99]. Three patients (33%) died, four (44%) survived with mRS 5 and two (22%) with mRS 4. Patients had a median NIHSS improvement of 5 compared to their initial NIHSS. Age was very strongly correlate to improvements in NIHSS (r2 = 0.90). CONCLUSION Data from this initial experience suggest emergent MIS hematoma evacuation in the setting of ICH with radiographic herniation is feasible and technically effective. Further randomized studies are required to determine if such an intervention offers overall benefits to patients and their families.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA.
| | - Georgios A Maragkos
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Kurt A Yaeger
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | | | - Trevor A Hardigan
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Vikram Vasan
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Ian C Odland
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Margaret Downes
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Zachary S Troiani
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Nicki Mohammadi
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Jacques Lara-Reyna
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Robert J Rothrock
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Daniel R Lefton
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
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22
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Lin JD, Schupper AJ, Matthew J, Lee N, Osorio JA, Marciano G, Lombardi JM, Sardar Z, Lehman RA, Lenke LG. A New Objective Radiographic Criteria for Diagnosis of Adult Idiopathic Scoliosis: Apical Pedicle Diameter Asymmetry. World Neurosurg 2023; 178:e141-e146. [PMID: 37437804 DOI: 10.1016/j.wneu.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 07/14/2023]
Abstract
OBJECTIVE We sought to test the hypothesis that a difference of ≥1 mm in pedicle diameter between the convex and concave pedicles at the apex of a lumbar curve is a sensitive and/or specific criteria for adult idiopathic scoliosis (AdIS). METHODS Thirty-nine operative patients with adult deformity and lumbar major curves were identified. A chart review was performed. Radiographic measurements included lumbar Cobb, curve apex, and Cobb levels involved. Apical pedicle diameter at the concavity and convexity of the curve apex were measured. RESULTS Among these 39 patients, the average Cobb angle was 48.3 degrees. Curve apex averaged at L1/2 (range L1-L3). The curves spanned 4.7 levels (range 3-7). Twenty-five curves had the apex to the left, while 14 had the apex to the right. The average pedicle diameter at the apex was 6.1 mm. Fourteen patients had apical pedicle diameter asymmetry (APDA) >1 mm. Most (7 of 8, or 87.5%) of the patients with a history of adult idiopathic scoliosis had APDA >1 mm. A minority (7 of 31, 22.5%) of patients without known history of adult idiopathic scoliosis had APDA >1 mm (P < 0.01). CONCLUSIONS Apical pedicle diameter asymmetry is among the sensitive diagnostic criteria for AdIS and may be useful for differentiating lumbar major AdIS from degenerative lumbar scoliosis. The sensitivity of APDA >1 mm is 87.5%, with specificity of 77.4%. We propose a new, sensitive radiographic criterion for adult idiopathic scoliosis. A difference of ≥1 mm in pedicle diameter between the convex and concave pedicles at that apex of a lumbar curve has a sensitivity of 87.5% and specificity of 77.4% for patient-reported history of adolescent scoliosis. It can be a useful tool as exclusion criteria for studies on AdIS.
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Affiliation(s)
- James D Lin
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, New York, USA
| | | | - Justin Matthew
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Nathan Lee
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Joseph A Osorio
- Department of Neurosurgery, University of California, San Diego, School of Medicine, San Diego, California, USA
| | - Gerard Marciano
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Joseph M Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Zeeshan Sardar
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Ronald A Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Lawrence G Lenke
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, New York, USA
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23
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Hrabarchuk EI, Dullea J, Downs M, Schupper AJ, Vasan V, McCarthy L, Asfaw Z, Quinones A, Kalagara R, Rodriguez B, Ali M, Li AY, Hannah TC, Choudhri TF. Bibliometric Analysis of International Medical Graduates and Professorship Promotion in Neurosurgery. World Neurosurg 2023; 178:e182-e188. [PMID: 37453729 DOI: 10.1016/j.wneu.2023.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/21/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND International medical graduates (IMGs) comprise ∼25% of physicians in the United States. Differences in promotion rates from assistant to associate to full professorship based on medical school location have been understudied. We aim to stratify odds of professional advancement by 3 categories: IMG with U.S. residency, IMG with international residency, and U.S. medical with U.S. residency training. METHODS We created and queried a database after exclusions of 1334 neurosurgeons including multiple demographic factors: academic productivity and promotion rates. Stratified logistic regression modeled odds of promotion including the variables: decades out of training, Scopus h-index, gender, and training location. Odds ratios (ORs) and 95% confidence intervals (CIs) for each variable were calculated. RESULTS Significant predictors of increased associate versus assistant professorship included decades out of training (OR = 2.519 [95% CI: 2.07-3.093], P < 0.0001) and Scopus h-index (OR = 1.085 [95% CI: 1.064-1.108], P < 0.0001) while international medical school with U.S. residency (OR = 0.471 [95% CI: 0.231-0.914], P = 0.0352) was associated with decreased promotion. Significant predictors of associate versus full professorship were decades out of training (OR = 2.781 [95% CI: 2.268-3.444], P < 0.0001) and Scopus h-index (OR = 1.064 [95% CI: 1.049-1.080], P < 0.0001). Attending medical school or residency internationally was not associated with odds of full professorship. CONCLUSIONS Time out of residency and Scopus h-index were associated with higher academic rank regardless of career level. Attending medical school internationally with U.S. residency was associated with lower odds of associate professorship promotion over 10 years. There was no relationship between IMG and full professorship promotion. IMGs who attended residency internationally did not have lower promotion rates. These findings suggest it may be harder for IMGs to earn promotion from assistant to associate professor in neurosurgery.
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Affiliation(s)
- Eugene I Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downs
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zerubabbel Asfaw
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Benjamin Rodriguez
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Y Li
- Department of Neurosurgery, University of Rochester School of Medicine, New York, New York, USA
| | - Theodore C Hannah
- Department of Neurosurgery, Lewis Katz School of Medicine Temple University, Philadelphia, Pennsylvania, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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24
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Rossitto CP, Vasan V, Downes MH, Yildiz S, Smith CJ, Liang JW, Schupper AJ, Hardigan T, Liu X, Ali M, Chapman EK, Devarajan A, Odland IC, Kellner CP, Mocco J. Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage. J Neurointerv Surg 2023:jnis-2023-020687. [PMID: 37696596 DOI: 10.1136/jnis-2023-020687] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 06/15/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. METHODS Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIs were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). CONCLUSIONS In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH.
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Affiliation(s)
- Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sema Yildiz
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Colton J Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John W Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xinyan Liu
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emily K Chapman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ian C Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Schupper AJ, Hadjipanayis CG. Novel approaches to targeting gliomas at the leading/cutting edge. J Neurosurg 2023; 139:760-768. [PMID: 36840741 DOI: 10.3171/2023.1.jns221798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 02/26/2023]
Abstract
Despite decades of clinical trials and surgical advances, the most common high-grade glioma, glioblastoma (GBM), remains an incurable disease with a dismal prognosis. Because of its infiltrative nature, GBM almost always recurs at the margin, or leading edge, where tumor cells invade the surrounding brain parenchyma. This region of GBMs is unique, or heterogeneous, with its own microenvironment that is different from the tumor bulk or core. The GBM microenvironment at the margin contains immunosuppressive constituents as well as invasive and therapy-resistant tumor cells that are difficult to treat. In addition, the blood-brain barrier remains essentially intact at the infiltrative margin of tumors; further limiting the effectiveness of therapies. The invasive margin creates the greatest challenge for neurosurgeons when managing these tumors. The current paradigm of resection of GBM tumors mainly focuses on resection of the contrast-enhancing component of tumors, while GBMs extend well beyond the contrast enhancement. The infiltrative margin represents a unique challenge and opportunity for solutions that may overcome current limitations in tumor treatments. In this review of the current literature, the authors discuss the current and developing advances focused on the detection and treatment of GBM at the infiltrative margin and how this could impact patient outcomes.
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Affiliation(s)
- Alexander J Schupper
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
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26
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Ali M, Ascanio LC, Smith C, Odland I, Murtaza-Ali M, Vasan V, Downes M, Schuldt BR, Lin A, Dullea J, Schupper AJ, Hardigan T, Asghar N, Mocco J, Kellner CP. Early and effective intracerebral hemorrhage evacuation is associated with a lower 1-year residual cavity volume and better functional outcomes. J Neurointerv Surg 2023:jnis-2023-020787. [PMID: 37620128 DOI: 10.1136/jnis-2023-020787] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 07/10/2023] [Accepted: 08/16/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND We explored the clinical significance of the residual hematoma cavity 1 year after minimally invasive intracerebral hemorrhage (ICH) evacuation. METHODS Patients presenting with spontaneous supratentorial ICH were evaluated for minimally invasive surgical evacuation. Inclusion criteria included age ≥18 years, preoperative hematoma volume (Hv) ≥15 mL, presenting National Institutes of Health Stroke Scale score ≥6, and premorbid modified Rankin Scale (mRS) score ≤3. Patients with longitudinal CT scans at least 3 months after evacuation were included in the study. Remnant cavity volumes (Cv) after evacuation were computed using semi-automatic volumetric segmentation software. Relative cavity volume (rCv) was defined as the ratio of the preoperative Hv to the remnant Cv. RESULTS 108 patients with a total of 484 head CT scans were included in the study. The median postoperative Cv was 2.4 (IQR 0.0-11) mL, or just 6% (0-33%) of the preoperative Hv. The median residual Cv on the final head CT scan a median of 13 months (range 11-27 months) after surgery had increased to 9.4 (IQR 3.1-18) mL, or 25% (10-60%) of the preoperative Hv. rCv on the final head CT scan was negatively associated with measures of operative success including evacuation percentage, postoperative Hv ≤15 mL, and decreased time from ictus to evacuation. rCv on the final head CT scan was also associated with a worse 6-month functional outcome (β per mRS point 17.6%, P<0.0001; area under the receiver operating characteristic curve 0.91). CONCLUSION After minimally invasive ICH evacuation the hematoma lesion decompresses significantly, with a residual Cv just 6% of the original lesion, but then gradually increases in size over time. Early and high percentage ICH evacuation may reduce the remnant Cv over time which, in turn, is associated with improved functional outcomes.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Luis C Ascanio
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ian Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Margaret Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Braxton Riley Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Anthony Lin
- Department of Pathology, Weill Cornell Medical College, New York, New York, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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27
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Schupper AJ, Khorasanizadeh M, Rossitto CP, Foster LD, Kellner CP, Suarez JI, Qureshi AI, Majidi S. Cigarette Smoking as a Risk Factor for Hematoma Expansion in Primary Intracerebral Hemorrhage: Analysis From a Randomized Clinical Trial. J Am Heart Assoc 2023; 12:e030431. [PMID: 37522176 PMCID: PMC10492975 DOI: 10.1161/jaha.123.030431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/10/2023] [Accepted: 06/26/2023] [Indexed: 08/01/2023]
Abstract
Background Cigarette smoking is a well-known risk factor for ischemic and hemorrhagic stroke. We evaluated the impact of smoking status on hematoma expansion and clinical outcome in patients with primary intracerebral hemorrhage. Methods and Results This is a post hoc exploratory analysis of the ATACH (Antihypertensive Treatment at Acute Cerebral Hemorrhage)-2 trial. Patients with intracerebral hemorrhage were randomized into intensive blood pressure lowering (systolic blood pressure, <139 mm Hg) versus standard blood pressure lowering (systolic blood pressure, 140-179 mm Hg) in this study. We compared the demographic characteristics; hematoma size, location, and expansion rate; and clinical outcome based on subjects' smoking status. Of a total of 914 patients in the trial with known smoking status, 439 (48%) patients were ever smokers (264 current smokers and 175 former smokers). Current and former smokers were younger and more likely to be men. Baseline Glasgow Coma Scale score and initial hematoma size did not vary based on smoking status. Ever smokers had higher rates of thalamic hemorrhage (42% versus 34%) and intraventricular hemorrhage (29% versus 23%); this rate was highest among former smokers versus current smokers (49% versus 35%, respectively). Ever smokers had a higher rate of hematoma expansion in 24 hours (adjusted relative risk [RR] [95% CI], 1.46 [1.08-1.96]) compared with nonsmokers on multivariate analysis. There was no significant difference in the rate of death and disability at 90 days between the 2 groups (adjusted RR [95% CI], 1.18 [0.998-1.40]). Conclusions Our analysis demonstrates cigarette smoking as an independent predictor for hematoma expansion. There was no significant difference in death and disability based on smoking status.
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Affiliation(s)
| | | | | | - Lydia D. Foster
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSC
| | | | - Jose I. Suarez
- Department of NeurologyJohns Hopkins HospitalBaltimoreMD
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute and Department of NeurologyUniversity of MissouriColumbiaMO
| | - Shahram Majidi
- Department of NeurosurgeryMount Sinai Health SystemNew YorkNY
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28
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Schupper AJ, Asfaw ZK, Shrivastava RK. Letter to the Editor: Sustaining the Life Force: The Importance of Resident Wellness in Neurosurgical Training. World Neurosurg 2023; 175:159-160. [PMID: 37365757 DOI: 10.1016/j.wneu.2023.04.038] [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: 04/09/2023] [Accepted: 04/10/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Alexander J Schupper
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, New York, USA.
| | - Zerubabbel K Asfaw
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, New York, USA
| | - Raj K Shrivastava
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, New York, USA
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Schupper AJ, Hrabarchuk EI, McCarthy L, Hadjipanayis CG. Improving Surgeon Well-Being: Ergonomics in Neurosurgery. World Neurosurg 2023; 175:e1220-e1225. [PMID: 37427701 DOI: 10.1016/j.wneu.2023.04.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 04/01/2023] [Accepted: 04/24/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Musculoskeletal disorders are common among surgeons, and affect most neurosurgeons over the course of their career. Although all subspecialist neurosurgeons may be affected by physical strain, spine surgeons and skull base surgeons have a high propensity for workplace injury as a result of long procedures with repetitive movements in strained physical positions. METHODS In this review, the prevalence of musculoskeletal disorders in neurosurgery, the state of innovation to improve ergonomics in the operating room for neurosurgeons, and potential limitations in advancing technology with the goal of maximizing neurosurgeon longevity are discussed. RESULTS Innovations such as robotics, the exoscope, and handheld devices with more degrees of freedom have allowed surgeons to maneuver instruments without exerting excessive effort, all while maintaining neutral body positioning, avoiding joint and muscle strain. CONCLUSIONS As new technology and innovation in the operating room develop, there has been a larger emphasis placed on maximizing surgeon comfort and neutral positioning, by minimizing force exertion and fatigue.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Eugene I Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Schupper AJ, Devarajan A, Lee DS, Perez E, Shrivastava RK. Ondine's curse: clinical presentation with diaphragmatic pacing and spontaneous respiratory recovery. Illustrative case. J Neurosurg Case Lessons 2023; 5:CASE233. [PMID: 37218735 PMCID: PMC10550651 DOI: 10.3171/case233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/16/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND The complexity of posterior fossa surgery can often lead to rare complications due to the anatomy involved. Vestibular schwannoma resection is a common pathology in the posterior fossa, often requiring surgical intervention. Given the proximity of this space to the brainstem, cranial nerve VII/VIII complex, and posterior inferior cerebellar artery (PICA), neurovascular complications are not infrequent. A rare vascular complication from this surgical approach is a lateral medullary infarction from injury to the lateral medullary segment of the proximal PICA, leading to central hypoventilation syndrome (CHS). OBSERVATIONS This report presents a unique case of a 51-year-old man who underwent a retrosigmoid craniectomy for resection of a vestibular schwannoma. Following surgery, the patient was unable to be weaned off the ventilator and was noted to become apneic while he slept, a clinical picture consistent with Ondine's curse. LESSONS This report discusses the anatomical considerations of this surgical corridor leading to this complication and the management of a patient with acquired Ondine's curse and reviews the scarce literature on this uncommon cause of acquired CHS.
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Affiliation(s)
| | | | | | - Enrique Perez
- Otolaryngology, School of Medicine at Mount Sinai, New York, New York
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Quinones A, Young T, Schupper AJ, Ali M, Hrabarchuk EI, Lamb CD, Genadry L, Kalagara R, Asfaw ZK, Gometz A, Lovell M, Choudhri TF. Effects of repetitive head trauma on symptomatology of subsequent sport-related concussion. J Neurosurg Pediatr 2023:1-8. [PMID: 37161993 DOI: 10.3171/2023.2.peds237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/17/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Adolescent participation in athletics continues to grow, leading to an increasing incidence of sports-related concussion (SRC). The current literature suggests that a greater number of prior concussions positively correlates with a greater number of total symptoms, but the specific concussion-related symptoms are not as well defined. The current study investigated the effects of prior recurrent head injury on the symptom profiles of student-athletes after another suspected concussion. METHODS A multicenter database consisting of 25,815 Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) results was filtered for student-athletes aged 12-22 years old who competed in 21 different sports. Patients were separated into 2 cohorts: athletes reporting a single prior concussion (SRC1) and athletes reporting 2 or more prior concussions (SRC2+). Comparisons were assessed for differences in 22 symptoms and 4 symptom clusters at baseline, first postinjury test (PI1), and second postinjury test (PI2) by using univariate and multivariate analyses. RESULTS No differences were seen between SRC1 (n = 2253) and SRC2+ (n = 976) at baseline. At PI1, the SRC2+ group (n = 286) had lower severity of headaches (p = 0.04) but increased nervousness (p = 0.042), irritability (p = 0.028), sadness (p = 0.028), visual problems (p = 0.04), and neuropsychiatric symptoms (p = 0.009) compared with SRC1 (n = 529). Multivariate analysis revealed decreased headache severity with increased prior concussion (β = -0.27,95% CI -0.45 to -0.09, p = 0.003). Multivariate analysis at PI2 demonstrated the SRC2+ cohort (n = 130) had increased cognitive (β = 1.22, 95% CI 0.27-2.18, p = 0.012), sleep (β = 0.63, 95% CI 0.17-1.08, p = 0.007), and neuropsychiatric (β = 0.67,95% CI 0.14-1.2,0.014) symptoms compared with SRC1 (n = 292). CONCLUSIONS At longitudinal follow-up, patients with a history of recurrent concussions reported greater symptom burden in cognitive, sleep, and neuropsychiatric symptom clusters but not migraine symptoms. This is an important distinction because migraine symptoms are often more easily distinguishable to patients, parents, and physicians. Careful assessment of specific symptoms should be considered in patients with a history of recurrent head injury prior to return to play.
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Affiliation(s)
- Addison Quinones
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Tirone Young
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | | | - Muhammad Ali
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Eugene I Hrabarchuk
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Colin D Lamb
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Lisa Genadry
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Roshini Kalagara
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Zerubabbel K Asfaw
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Alex Gometz
- 2Concussion Management of New York, New York, New York; and
| | - Mark Lovell
- 3Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tanvir F Choudhri
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
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Rossitto CP, Odland LC, Oemke H, Cruz D, Kalagara R, Schupper AJ, Hardigan T, Philbrick BD, Schuldt BR, Downes MH, Vasan V, Devarajan A, Ali M, Bederson JB, Kellner CP. External ventricular drain training in medical students improves procedural accuracy and attitudes towards virtual reality. World Neurosurg 2023:S1878-8750(23)00594-6. [PMID: 37149087 DOI: 10.1016/j.wneu.2023.04.108] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/17/2023] [Accepted: 04/24/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVE Neurosurgery residents face a learning curve at the beginning of residency. Virtual reality (VR) training may alleviate challenges through an accessible, reusable, anatomical model. METHODS Medical students performed external ventricular drain (EVD) placements in VR to characterize the learning curve from novice to proficient. Distance from catheter to Foramen of Monro and location with respect to ventricle were recorded. Changes in attitudes towards VR were assessed. Neurosurgery residents performed EVD placements to validate proficiency benchmarks. Resident and student impressions of the VR model were compared. RESULTS Twenty-one students with no neurosurgical experience and 8 neurosurgery residents participated. Student performance improved significantly from trial 1 to 3 (15 mm [12.1-20.70] vs 9.7 [5.8-15.3], p=.02). Student attitudes regarding VR utility improved significantly post-trial. The distance to Foramen of Monro was significantly shorter for residents than for students in trial 1 (9.05 [8.25-10.73] vs 15 [12.1-20.70], p=.007) and trial 2 (7.45 [6.43-8.3] vs 19.5 [10.9-27.6], p=.002). By trial 3 there was no significant difference (10.1 [8.63-10.95 vs 9.7 [5.8-15.3], p=.62). Residents and students provided similarly positive feedback for VR in resident curricula, patient consent, preoperative practice and planning. Residents provided more neutral-to-negative feedback regarding skill development, model fidelity, instrument movement, and haptic feedback. CONCLUSIONS Students showed significant improvement in procedural efficacy which may simulate resident experiential learning. Improvements in fidelity are needed before VR can become a preferred training technique in neurosurgery.
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Affiliation(s)
- Christina P Rossitto
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Lan C Odland
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Holly Oemke
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Trevor Hardigan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Brandon D Philbrick
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Braxton R Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margaret H Downes
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alex Devarajan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Schupper AJ, Hardigan TA, Mehta A, Yim B, Yaeger KA, De Leacy R, Fifi JT, Mocco J, Majidi S. Sex and Racial Disparity in Outcome of Aneurysmal Subarachnoid Hemorrhage in the United States: A 20-Year Analysis. Stroke 2023; 54:1347-1356. [PMID: 37094033 DOI: 10.1161/strokeaha.122.041488] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is associated with high rate of morbidity and mortality. We aimed to assess prognostic impact of sex, race, and ethnicity in these patients. METHODS Nationwide Inpatient Sample (2000-2019) was used to identify patients presenting with aneurysmal subarachnoid hemorrhage as primary diagnosis. Patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities, type of the hospital, and treatment modality used for aneurysm repair were extracted. The previously validated Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale was used to estimate the clinical severity. Discharge destination and in-hospital mortality was used as outcome measured. The impact of race/ethnicity and sex on clinical outcome was analyzed using multivariate regression models. RESULTS A total of 161 086 patients with aneurysmal subarachnoid hemorrhage were identified. Mean age was 55.0±13.8 years. Sixty-nine percent of the patients were female, 60% White patients, and 17% Black patients. There was no difference in the Nationwide Inpatient Sample Subarachnoid Hemorrhage Severity Scale score between the 2 sexes. Women had significantly lower odds of good clinical outcome (defined as discharge to home or acute rehabilitation facility; RR, 0.83 [95% CI, 0.74-0.94]; P=0.004). Hispanic patients (RR, 1.12 [95% CI, 1.07-1.17]; P<0.001) had higher odds of excellent clinical outcome compared with White patients, and lower risk of mortality were observed in Black patients (RR, 0.73 [95% CI, 0.66-0.81]) and Hispanic patients (RR, 0.78 [95% CI, 0.70-0.86]) compared with the White patients. CONCLUSIONS In this nationally representative study, women were less likely to have excellent outcomes following aneurysmal subarachnoid hemorrhage, and White patients had disproportionately higher likelihood of worse clinical outcomes. Lower rates of mortality were seen among Black and Hispanic patients.
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Affiliation(s)
- Alexander J Schupper
- Icahn School of Medicine at Mount Sinai, New York, NY (A.J.S., T.A.H., R.D.L., J.T.F.)
| | - Trevor A Hardigan
- Icahn School of Medicine at Mount Sinai, New York, NY (A.J.S., T.A.H., R.D.L., J.T.F.)
| | - Amol Mehta
- Department of Neurology, Columbia University Irving Medical Center, New York, NY (A.M.)
| | - Benjamin Yim
- East Bay Brain and Spine, Walnut Creek, CA (B.Y.)
| | - Kurt A Yaeger
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (K.A.Y., S.M.)
| | - Reade De Leacy
- Icahn School of Medicine at Mount Sinai, New York, NY (A.J.S., T.A.H., R.D.L., J.T.F.)
| | - Johanna T Fifi
- Icahn School of Medicine at Mount Sinai, New York, NY (A.J.S., T.A.H., R.D.L., J.T.F.)
| | - J Mocco
- Mount Sinai Hospital, New York, NY (J.M.)
| | - Shahram Majidi
- Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY (K.A.Y., S.M.)
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Schupper AJ, Carr M, Philbrick B, Chennareddy S, Kalagara R, Turner D, Kellner CP. 417 An Athlete-Oriented Holistic Coaching Program Targeting Performance and Wellbeing in Neurosurgery Residents. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Rivera D, Schupper AJ, Bouras A, Anastasiadou M, Kleinberg L, Kraitchman DL, Attaluri A, Ivkov R, Hadjipanayis CG. Neurosurgical Applications of Magnetic Hyperthermia Therapy. Neurosurg Clin N Am 2023; 34:269-283. [PMID: 36906333 PMCID: PMC10726205 DOI: 10.1016/j.nec.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Magnetic hyperthermia therapy (MHT) is a highly localized form of hyperthermia therapy (HT) that has been effective in treating various forms of cancer. Many clinical and preclinical studies have applied MHT to treat aggressive forms of brain cancer and assessed its role as a potential adjuvant to current therapies. Initial results show that MHT has a strong antitumor effect in animal studies and a positive association with overall survival in human glioma patients. Although MHT is a promising therapy with the potential to be incorporated into the future treatment of brain cancer, significant advancement of current MHT technology is required.
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Affiliation(s)
- Daniel Rivera
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, Suite F-158, Pittsburgh, PA 15213, USA; Brain Tumor Nanotechnology Laboratory, UPMC Hillman Cancer Center, 5117 Centre Avenue, Pittsburgh, PA 15232, USA
| | - Alexander J Schupper
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Alexandros Bouras
- Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, Suite F-158, Pittsburgh, PA 15213, USA; Brain Tumor Nanotechnology Laboratory, UPMC Hillman Cancer Center, 5117 Centre Avenue, Pittsburgh, PA 15232, USA
| | - Maria Anastasiadou
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Lawrence Kleinberg
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, 1550 Orleans Street, Baltimore, MD 21231-5678, USA
| | - Dara L Kraitchman
- Russell H Morgan Department of Radiology and Radiological Science, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Anilchandra Attaluri
- Department of Mechanical Engineering, The Pennsylvania State University, 777 West Harrisburg Pike Middletown, PA 17057, USA
| | - Robert Ivkov
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, 1550 Orleans Street, Baltimore, MD 21231-5678, USA; Department of Oncology, Johns Hopkins University School of Medicine, 1550 Orleans Street, Baltimore, MD 21231-5678, USA; Department of Mechanical Engineering, Johns Hopkins University, Whiting School of Engineering, 3400 North Charles Street, Baltimore, MD 21218, USA; Department of Materials Science and Engineering, Johns Hopkins University, Whiting School of Engineering, 3400 North Charles Street, Baltimore, MD 21218, USA
| | - Constantinos G Hadjipanayis
- Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA; Department of Neurological Surgery, University of Pittsburgh, 200 Lothrop Street, Suite F-158, Pittsburgh, PA 15213, USA; Brain Tumor Nanotechnology Laboratory, UPMC Hillman Cancer Center, 5117 Centre Avenue, Pittsburgh, PA 15232, USA.
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Chennareddy S, Kalagara R, Schupper AJ, Carr MT, Philbrick B, Turner D, Kellner CP. 420 Coaching for Success: An Athlete-Centered Approach to Optimizing Performance and Protecting Wellbeing in Neurosurgery Residents. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Asfaw ZK, Schupper AJ, Durbin J, Kellner C, Shrivastava R. Black clouds in surgery: A study of surgical resident workload and burnout. Surgeon 2023; 21:71-77. [PMID: 36858912 DOI: 10.1016/j.surge.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/12/2022] [Revised: 12/16/2022] [Accepted: 01/23/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The concept of a 'black cloud' is a common unfounded perception in the healthcare workforce that attributes a heavier workload to specific individuals or teams. Prior studies in non-surgical disciplines have demonstrated that 'black cloud' perceptions are not associated with workload, albeit such perceptions may influence behavior. The influence of 'black cloud' perceptions on surgical resident workload and burnout remains to be investigated. This study assesses the associations between 'black cloud' self-perception with actual workload and burnout among surgical residents in different specialties. METHODS A cross-sectional survey study of postgraduate year (PGY) 2 and 3 residents enrolled in different surgical residencies at the Icahn School of Medicine at Mount Sinai was conducted between September-November 2021. RESULTS The survey response rate was 62.1% (41/66). 46.3% of respondents were female. The majority of subjects were single (61%) and PGY2 trainees (56.1%). In a multivariate regression analysis demographic factors and workload variables, such as the number of pages responded, notes, and amount of sleep, were not significant predictors of a 'black cloud'-self-perception. A significantly lower Burnout Index Score (BIS) was observed among females (p< .001). A significantly higher BIS was observed among residents who are single (p = .003), training in general surgery (p = .02), and orthopedic surgery (p = .03). There was no significant association between 'black cloud' self-perception and BIS. DISCUSSION The findings demonstrate that a 'black cloud' self-perception is not associated with a high workload and burnout among surgical residents. Gender, marriage/domestic partnership, and certain surgical specialties influenced burnout among the study cohort.
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Affiliation(s)
- Zerubabbel K Asfaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Durbin
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Raj Shrivastava
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Schupper AJ, Lin D J, Gologorsky Y. Bone Morphogenic Protein in Anterior Cervical Discectomy and Fusion: Time for a Fresh Look? World Neurosurg 2023:S1878-8750(23)00466-7. [PMID: 37028481 DOI: 10.1016/j.wneu.2023.03.142] [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] [Indexed: 04/08/2023]
Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - James Lin D
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yakov Gologorsky
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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Schupper AJ, Kaufman M, Reidler JS, Arginteanu MS, Moore FM, Steinberger A, Syed ON, Yao KC, Gologorsky Y. Spinal deformity surgery in patients for whom blood transfusion is not an option: a single-center experience. J Neurosurg Spine 2023; 38:348-356. [PMID: 36866794 DOI: 10.3171/2022.11.spine221061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/15/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. METHODS The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. RESULTS Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9-70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5-16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200-3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3-28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. CONCLUSIONS With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.
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Affiliation(s)
| | - Margit Kaufman
- and Departments of2Anesthesiology and Critical Care Medicine
| | - Jay S Reidler
- 3Orthopaedic Surgery, Mount Sinai Health System, New York, New York
- 4Orthopaedic Surgery, and
| | - Marc S Arginteanu
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Frank M Moore
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Alfred Steinberger
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Omar N Syed
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Kevin C Yao
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
| | - Yakov Gologorsky
- Departments of1Neurosurgery and
- 5Neurosurgery, Englewood Health, Englewood, New Jersey
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Schupper AJ, Eskandari R, Kosnik-Infinger L, Olivera R, Nangunoori R, Patel S, Williamson R, Yu A, Hadjipanayis CG. A Multicenter Study Investigating the Surgeon Experience with a Robotic-Assisted Exoscope as Part of the Neurosurgical Armamentarium. World Neurosurg 2023; 173:e571-e577. [PMID: 36842529 DOI: 10.1016/j.wneu.2023.02.094] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 02/16/2023] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND Improvement of visualization tools in neurosurgery such as the exoscope has raised the question of how this technology compares to the conventional microscope for surgeon ergonomics, discomfort, and patient outcomes. Exoscopes have the advantage of greater optical zoom, resolution, and illumination at a lower light intensity. Heads-up display for both the primary surgeon and other assistants permits neutral positioning of the surgeons while placing the camera in more angled positions. In a survey sample, this study assesses the surgeon experience utilizing 3D exoscope in general neurosurgery cases. METHODS Data weere recorded by 8 surgeons at 5 separate hospitals utilizing a mobile phone application survey. Surgeons recorded information about case type, intraoperative clinical outcomes such as blood loss and extent of resection, whether fluorescence visualization was used, as well as surgeon pain when compared to matched cases using conventional tools. RESULTS A total of 155 neurosurgical cases were recorded in this multisite study, including 72% cranial cases and 28% spinal cases. Of the cranial cases, 76% were brain tumor resections (31% of which were brain metastases). Surgeons reported significantly less neck (P < 0.0001) and back (P < 0.0001) pain in cases when using the robotic exoscope compared with the conventional microscope or surgical loupes. Surgeons did not convert to a microscope in any case. CONCLUSIONS The exoscope provides excellent delineation of tissue with high resolution. Surgeon pain was markedly reduced with the robotic exoscope when compared with conventional technology, which may reduce work-related injury and fatigue, potentially leading to better patient outcomes.
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Affiliation(s)
- Alexander J Schupper
- School of Medicine at Mount Sinai, Department of Neurological Surgery, New York City, New York, USA
| | - Ramin Eskandari
- Medical University of South Carolina, Department of Neurological Surgery, Charleston, South Carolina, USA
| | - Libby Kosnik-Infinger
- Medical University of South Carolina, Department of Neurological Surgery, Charleston, South Carolina, USA
| | - Raul Olivera
- University of South Florida, Department of Neurological Surgery, Tampa, Florida, USA
| | | | - Sunil Patel
- Medical University of South Carolina, Department of Neurological Surgery, Charleston, South Carolina, USA
| | - Richard Williamson
- Allegheny Health Network, Department of Neurological Surgery, Pittsburgh, Pennsylvania, USA
| | - Alexander Yu
- Allegheny Health Network, Department of Neurological Surgery, Pittsburgh, Pennsylvania, USA
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Li AY, McCarthy L, Hrabarchuk E, Spiera Z, Marayati NF, Schupper AJ, Hannah TC, Genadry L, Ali M, Quinones A, Kalagara R, Baron R, Sideras P, Naidich TP, Choudhri TF. Novel Grading Scales for Static and Flexion-Extension Magnetic Resonance Imaging in Patients with Cervical Spondylotic Myelopathy. World Neurosurg 2023; 173:e218-e227. [PMID: 36787858 DOI: 10.1016/j.wneu.2023.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/07/2022] [Revised: 02/05/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Flexion-extension magnetic resonance imaging (MRI) has potential to identify cervical pathology not detectable on conventional static MRI. Our study evaluated standard quantitative and novel subjective grading scales for assessing the severity of cervical spondylotic myelopathy in dynamic sagittal MRI as well as in static axial and sagittal images. METHODS Forty-five patients underwent both conventional and flexion-extension MRI prior to anterior cervical discectomy and fusion from C4 through C7. In addition to measuring Cobb angles and cervical canal diameter, grading scales were developed for assessment of vertebral body translation, loss of disc height, change in disc contour, deformation of cord contour, and cord edema. Data were collected at all levels from C2-C3 through C7-T1. Variations in measurements between cervical levels and from flexion through neutral to extension were assessed using Mann-Whitney, Kruskal-Wallis, and two-way ANOVA tests. RESULTS Cervical canal diameter, vertebral translation, and posterior disc opening changed significantly from flexion to neutral to extension positions (P < 0.01). When comparing operative versus nonoperative cervical levels, significant differences were found when measuring sagittal cervical canal dimensions, vertebral translation, and posterior disc opening (P < 0.01). Degenerative loss of disc height, disc dehydration, deformation of ventral cord contour, and cord edema were all significantly increased at operative levels versus nonoperative levels (P < 0.01). CONCLUSIONS Flexion-extension MRI demonstrated significant changes not available from conventional MRI. Subjective scales for assessing degenerative changes were significantly more severe at levels with operative cervical spondylotic myelopathy. The utility of these scales for planning surgical intervention at specific and adjacent levels is currently under investigation.
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Affiliation(s)
- Adam Y Li
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eugene Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zachary Spiera
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naoum Fares Marayati
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Theodore C Hannah
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lisa Genadry
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roshini Kalagara
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rebecca Baron
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Panagiotis Sideras
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Thomas P Naidich
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Tanvir F Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Ali M, Asghar N, Hannah T, Schupper AJ, Li A, Dreher N, Murtaza-Ali M, Vasan V, Nakadar Z, Alasadi H, Lin A, Hrabarchuk E, Quinones A, McCarthy L, Asfaw Z, Dullea J, Gometz A, Lovell M, Choudhri T. A multicenter, longitudinal survey of headaches and concussions among youth athletes in the United States from 2009 to 2019. J Headache Pain 2023; 24:6. [PMID: 36755244 PMCID: PMC9909942 DOI: 10.1186/s10194-022-01528-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/17/2022] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVE/ BACKGROUND Chronic headaches and sports-related concussions are among the most common neurological morbidities in adolescents and young adults. Given that the two can overlap in presentation, studying the effects of one on another has proven difficult. In this longitudinal study, we sought to assess the relationship between chronic headaches and concussions, analyzing the role of historic concussions on chronic headaches, as well as that of premorbid headaches on future concussion incidence, severity, and recovery. METHODS This multi-center, longitudinal cohort study followed 7,453 youth athletes who were administered demographic and clinical surveys as well as a total of 25,815 Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) assessments between 2009 and 2019. ImPACT was administered at baseline. Throughout the season concussions were examined by physicians and athletic trainers, followed by re-administration of ImPACT post-injury (PI), and at follow-up (FU), a median of 7 days post-concussion. Concussion incidence was calculated as the total number of concussions per patient years. Concussion severity and recovery were calculated as standardized deviations from baseline to PI and then FU in Symptom Score and the four neurocognitive composite ImPACT scores: Verbal Memory, Visual Memory, Processing Speed, and Reaction Time. Data were collected prospectively in a well-organized electronic format supervised by a national research-oriented organization with rigorous quality assurance. Analysis was preformed retrospectively. RESULTS Of the eligible athletes, 1,147 reported chronic headaches (CH) at the start of the season and 6,306 reported no such history (NH). Median age of the cohort was 15.4 ± 1.6 years, and students were followed for an average of 1.3 ± 0.6 years. A history of concussions (OR 2.31, P < 0.0001) was associated with CH. Specifically, a greater number of past concussions (r2 = 0.95) as well as concussions characterized by a loss of consciousness (P < 0.0001) were associated with more severe headache burden. The CH cohort had a greater future incidence of concussion than the NH cohort (55.6 vs. 43.0 per 100 patient-years, P < 0.0001). However, multivariate analysis controlling for demographic, clinical, academic, and sports-related variables yielded no such effect (OR 0.99, P = 0.85). On multivariable analysis the CH cohort did have greater deviations from baseline to PI and FU in Symptom Score (PI OR per point 1.05, P = 0.01, FU OR per point 1.11, P = 0.04) and Processing Speed (OR per point 1.08, P = 0.04), suggesting greater concussion severity and impaired symptomatic recovery as compared to the NH cohort. CONCLUSION A history of concussions was a significant contributor to headache burden among American adolescents and young adults. However, those with chronic headaches were not more likely to be diagnosed with a concussion, despite presenting with more severe concussions that had protracted recovery. Our findings not only suggest the need for conservative management among youth athletes with chronic headaches, they also indicate a potential health care gap in this population, in that those with chronic headaches may be referred for concussion diagnosis and management at lower rates than those with no such comorbidity.
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Affiliation(s)
- Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA.
| | - Nek Asghar
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Theodore Hannah
- Department of Neurosurgery, Lewis Katz School of Medicine at Temple University, 19140, Philadelphia, PA, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Adam Li
- Department of Neurosurgery, University of Rochester School of Medicine and Dentistry, 14642, Rochester, NY, USA
| | - Nickolas Dreher
- Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, 10032, NY, USA
| | - Muhammad Murtaza-Ali
- Department of Anthropology, State University of New York at Binghamton, 13902, NY, USA
| | - Vikram Vasan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Zaid Nakadar
- Department of Neurosurgery, State University of New York Downstate Health Sciences University, 11203, NY, USA
| | - Husni Alasadi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Anthony Lin
- Department of Pathology, Joan & Sanford I. Weill Medical College of Cornell University, 10021, NY, USA
| | - Eugene Hrabarchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Addison Quinones
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Lily McCarthy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Zerubabbel Asfaw
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Jonathan Dullea
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
| | - Alex Gometz
- Concussion Management of New York, 10021, NY, USA
| | - Mark Lovell
- Department of Neurology, The University of Pittsburgh Medical Center, 15260, Pittsburgh, PA, USA
| | - Tanvir Choudhri
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 10021, NY, USA
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Rossitto CP, Vasan V, Downes MH, Yildiz S, Liang J, Schupper AJ, Hardigan T, Chapman EK, Mocco J, Kellner CP. Abstract TP87: Predictors Of Diffusion-weighted Imaging Lesion Burden In Patients After Minimally Invasive Surgery For Intracerebral Hemorrhage. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
The etiology of diffusion-weighted imaging (DWI) lesions in patients after minimally invasive surgery (MIS) for acute intracerebral hemorrhage (ICH) remains unclear.
Methods:
Postoperative brain MRIs of patients with spontaneous ICH from 2016-2021 who underwent imaging within one month of MIS were reviewed. DWI lesions were quantified. Lesions within 10 mm of the hematoma were excluded. Siderosis and microbleeds were identified. Leukoaraiosis was quantified using the Fazekas score. Univariate analyses were conducted to determine predictors of DWI lesion burden, and variables with P≤0.1 were included in multivariate analyses.
Results:
DWI lesions were present in 84 (49%) postoperative MRIs. The average number of DWI lesions was 2.11 (range 0-74, SD 6.50). Factors associated with DWI burden in univariate analyses included increased presenting systolic blood pressure (SBP) (P=0.003), Fazekas score (P=0.004), delta SBP on day of admission (P=0.034), preoperative angiogram (P=0.062), microbleeds on MRI (P=0.065), increased presenting National Institutes of Health Stroke Score (P=0.066), presence of intraventricular hemorrhage (P=0.069), and decreased presenting Glasgow Coma Scale (P=0.076). Upon multivariate analysis, increased Fazekas score (OR 2.04, 95% CI 1.21-3.43, P=0.008), presenting SBP (OR 1.04, 95% CI 1.00-1.06, P=0.014), and preoperative angiogram (OR 10.35, 95% CI 1.44-74.36], P=0.020) were predictive of DWI burden.
Conclusions:
In this unique postoperative ICH cohort, white matter changes, presenting SBP, and preoperative angiogram predicted DWI lesion burden. Larger studies are needed to understand the implications of DWI burden after MIS for ICH recovery.
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Affiliation(s)
| | | | | | | | | | | | | | | | - J Mocco
- Mount Sinai Hosp, New York, NY
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Schupper AJ, Gologorsky Y. Neuromonitoring During Condylar Screw Placement. World Neurosurg 2023; 169:118. [PMID: 36184045 DOI: 10.1016/j.wneu.2022.09.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Yakov Gologorsky
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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45
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Schupper AJ, Lin JD, Osorio JA, Lee NJ, Steinberger JM, Lombardi JM, Lehman RA, Lenke LG. Freehand Juxtapedicular Screws Placed in the Apical Concavity of Adult Idiopathic Scoliosis Patients: Technique, Computed Tomography Confirmation, and Radiographic Results. Neurospine 2022; 19:1116-1121. [PMID: 36597645 PMCID: PMC9816604 DOI: 10.14245/ns.2244798.399] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 08/31/2022] [Accepted: 11/12/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE The purpose of this study is to highlight our technique for freehand placement of juxtapedicular screws along with intraoperative computed tomography (CT) and radiographic results. METHODS Consecutive patients with adult idiopathic scoliosis undergoing primary surgery by the senior author were identified. All type D (absent/slit like channel) pedicles were identified on preoperative CT. Three-dimensional visualization software was used to measure screw angulation and purchase. Radiographs were measured by a fellowship trained spine surgeon. The freehand technique was used to place all screws in a juxtapedicular fashion without any fluoroscopic, radiographic, navigational or robotic assistance. RESULTS Seventy-three juxtapedicular screws were analyzed. The most common level was T7 (9 screws) on the left and T5 (12 screws) on the right. The average medial angulation was 20.7° (range, 7.1°-36.3°), lateral vertebral body purchase was 13.4 mm (range, 0-28.9 mm), and medial vertebral body purchase was 21.1 mm (range, 8.9-31.8 mm). More than half (53.4%) of the screws had bicortical purchase. Two screws were lateral on CT scan, defined by the screw axis lateral to the lateral vertebral body cortex. No screws were medial. There was a difference in medial angulation between screws with (n = 58) and without (n = 15) lateral body purchase (22.0 ± 4.9 vs. 15.5 ± 4.5, p < 0.001). Three of 73 screws were repositioned after intraoperative CT. There were no neurovascular complications. The mean coronal cobb corrections for main thoracic and lumbar curves were 83.0% and 80.5%, respectively, at an average of 17.5 months postoperative. CONCLUSION Freehand juxtapedicular screw placement is a safe technique for type D pedicles in adult idiopathic scoliosis patients.
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Affiliation(s)
| | - James D. Lin
- Department of Orthopedic Surgery, Mount Sinai Hospital, New York, NY, USA,Corresponding Author James D. Lin Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave Levy Place, New York, NY 10029, USA
| | - Joseph A. Osorio
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Nathan J. Lee
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | | | - Joseph M. Lombardi
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Ronald A. Lehman
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Lawrence G. Lenke
- The Spine Hospital, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
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Quinones A, Tang JE, Vasan V, Li T, Schupper AJ, Ali M, White CA, Hannah TC, Asfaw Z, Li AY, Durbin J, Arvind V, Kim JS, Choudhri TF. Trends in Online Patient Perspectives of Neurosurgeons: A Sentiment Analysis. Neurosurgery Open 2022. [DOI: 10.1227/neuopn.0000000000000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Abstract
To aid surgeons in more complete and safe resection of brain tumors, adjuvant technologies have been developed to improve visualization of target tissue. Fluorescence-guided surgery relies on the use of fluorophores and specific light wavelengths to better delineate tumor tissue, inflammation, and areas of blood-brain barrier breakdown. 5-aminolevulinic acid (5-ALA), the first fluorophore developed specifically for brain tumors, accumulates within tumor cells, improving visualization of tumors both at the core, and infiltrative margin. Here, we describe the background of how 5-ALA integrated into the modern neurosurgery practice, clinical evidence for the current use of 5-ALA, and future directions for its role in neurosurgical oncology. Maximal safe resection remains the standard of care for most brain tumors. Gross total resection of high-grade gliomas (HGGs) is associated with greater overall survival and progression-free survival (PFS) in comparison to subtotal resection or adjuvant treatment therapies alone.1-3 A major challenge neurosurgeons encounter when resecting infiltrative gliomas is identification of the glioma tumor margin to perform a radical resection while avoiding and preserving eloquent regions of the brain. 5-aminolevulinic acid (5-ALA) remains the only optical-imaging agent approved by the FDA for use in glioma surgery and identification of tumor tissue.4 A multicenter randomized, controlled trial revealed that 5-ALA fluorescence-guided surgery (FGS) almost doubled the extent of tumor resection and also improved 6-month PFS.5 In this review, we will highlight the current evidence for use of 5-ALA FGS in brain tumor surgery, as well as discuss the future directions for its use.
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Affiliation(s)
- David J McCracken
- Department of Neurosurgery, Piedmont Healthcare, Atlanta, Georgia, USA
| | - Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Nikita Lakomkin
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - James Malcolm
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | - Constantinos G Hadjipanayis
- Corresponding Author: Constantinos G. Hadjipanayis, MD, PhD, Mount Sinai Union Square, 10 Union Square East, Suite 5E, New York, NY 10003, USA ()
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Abstract
Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) is an ablative procedure using heat from a laser to provide cytoreduction in tissue. It is a minimally invasive procedure that has been used in intracranial pathologies such as high-grade gliomas, metastatic lesions, epilepsy, and other lesions. While LITT may offer a more acceptable complication profile compared to open surgery, the role of laser therapy for intracranial lesions in current treatment paradigms continues to evolve. This review will focus on the background and application of LITT, the current evidence for its use, and future directions for the technology.
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Affiliation(s)
- Alexander J Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Tori Chanenchuk
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Anna Racanelli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Gabrielle Price
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, USA
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Downtown Union Square, Mount Sinai Health System, New York, New York, USA
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Shuman WH, Baron RB, Neifert SN, Martini ML, Chapman EK, Schupper AJ, Caridi JM, Steinberger J. MIS-TLIF Procedure is Improving With Experience: Systematic Review of the Learning Curve Over the Last Decade. Clin Spine Surg 2022; 35:376-382. [PMID: 35354767 DOI: 10.1097/bsd.0000000000001331] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/01/2022] [Indexed: 01/25/2023]
Abstract
STUDY DESIGN This was a systematic review. OBJECTIVE This review evaluates the minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) learning curve in the literature and compares outcomes during and after completing the curve. SUMMARY OF BACKGROUND DATA MIS-TLIF are performed for various spine conditions. Proponents cite improved clinical outcomes while critics highlight the steep learning curve to attain proficiency. METHODS Literature searches on Medline and Embase utilized relevant subject headings and keywords. Manuscripts reporting learning curve statistics were included. Monotonic trends of operative duration were assessed with Mann-Kendall nonparametric testing. RESULTS Nine studies met inclusion criteria. Number of patients ranged from 26 to 150 (average 83.2, median of 86). Commonly reported metrics included number of procedures to complete the curve, operative duration, blood loss, ambulation time, length of stay, complication rate, follow-up visual analogue scale (VAS) for back and leg pain, and fusion rate. Various methods were employed to determine number of cases to complete the curve, all involving operative duration. Number of cases ranged from 14 to 44. A significant negative trend for operative duration of cases during the learning curve (τ=-0.733, P =0.039) was found over the years that studies were published. Initial complication rates varied from 6.8% to 23.8%. Initial VAS-back and VAS-leg ranged from 0.8 to 2.9 and 0.5 to 2.3, respectively. While definitions of "good" fusion varied, fusion rates meeting Bridwell grade I or II during the learning curve ranged from 84.0% to 95.2%. CONCLUSIONS Surgeons in their learning curve have become faster at the MIS-TLIF procedure. Clinical outcomes including postoperative pain and fusion rates showed satisfactory results, but surgeons learning the procedure should take measures to minimize complications in early cases, such as utilizing novel navigation technology or supervision from more experienced surgeons. Learning curve research methodology could benefit from standardization.
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Affiliation(s)
- William H Shuman
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, NY
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Hannah TC, Kalagara R, Ali M, Schupper AJ, Li AY, Spiera Z, Marayati NF, Quinones A, Asfaw ZK, Vasan V, Hrabarchuk EI, McCarthy L, Gometz A, Lovell M, Choudhri T. Evaluation of differences across age groups in the incidence, severity, and recovery of concussion in adolescent student-athletes from 2009 to 2019. J Neurosurg Pediatr 2022; 30:1-9. [PMID: 35907188 DOI: 10.3171/2022.6.peds22127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 04/12/2022] [Accepted: 06/23/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Concussion incidence is known to be highest in children and adolescents; however, there is conflicting evidence about the effect of age on concussion risk and recovery within the adolescent age range. The heterogeneity of results may be partially due to the use of age groupings based on convenience, making comparisons across studies difficult. This study evaluated the independent effect of age on concussion incidence, severity, and recovery in student-athletes aged 12-18 years using cluster analysis to define groupings. METHODS Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores of 11,403 baseline tests and 4922 postinjury tests were used to calculate the incidence rates for adolescent student-athletes grouped into 3 age bands (12-13, 14-15, and 16-18 years of age) on the basis of clustering analysis. The recently created Severity Index was used to compare concussion severity between groups. Follow-up tests for subjects who sustained a concussion were used to evaluate recovery time. The chi-square test and 1-way ANOVA were used to compare differences in demographic characteristics and concussion incidence, severity, and recovery. Multivariable logistic and linear regressions were used to evaluate the independent effects of age on concussion incidence and severity, respectively. Multivariable Cox hazard regression was used to evaluate differences in recovery time. Further analyses were conducted to directly compare findings across studies on the basis of the age groupings used in prior studies. RESULTS Multivariable regression analyses demonstrated that the 14- to 15-year-old age group had a significantly higher concussion incidence than both the 12- to 13-year-old (14- to 15-year-old group vs 12- to 13-year-old group, OR 1.57, 95% CI 1.16-2.17, p = 0.005) and 16- to 18-year-old (16- to 18-year-old group vs 14- to 15-year-old group, OR 0.79, 95% CI 0.69-0.91, p = 0.0008) age groups. There was no difference in incidence between the 12- to 13-year-old and 16- to 18-year-old groups (16- to 18-year group vs 12- to 13-year group, OR 1.26, 95% CI 0.93-1.72, p = 0.15). There were also no differences in concussion severity or recovery between any groups. CONCLUSIONS This study found that concussion incidence was higher during mid-adolescence than early and late adolescence, suggesting a U-shaped relationship between age and concussion risk over the course of adolescence. Age had no independent effect on concussion severity or recovery in the 12- to 13-, 14- to 15-, and 16- to 18-year-old groups. Further analysis of the various age groups revealed that results may vary significantly with minor changes to groupings, which may explain the divergent results in the current literature on this topic. Thus, caution should be taken when interpreting the results of this and all similar studies, especially when groupings are based on convenience.
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Affiliation(s)
- Theodore C Hannah
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Roshini Kalagara
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Muhammad Ali
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | | | - Adam Y Li
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Zachary Spiera
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | | | - Addison Quinones
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Zerubabbel K Asfaw
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Vikram Vasan
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Eugene I Hrabarchuk
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Lily McCarthy
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Alex Gometz
- 2Physical Medicine and Rehabilitation, Concussion Management of New York, New York, New York; and
| | - Mark Lovell
- 3Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Tanvir Choudhri
- 1Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
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