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Saint-Germain MA, Kramer P, Weber-Levine C, Jiang K, Al-Mistarehi AH, Redmond KJ, Lee SH, Bettegowda C, Theodore N, Lubelski D. Characterizing the presentation, management, and clinical outcomes of patients with intradural spinal chordomas: a systematic review. Neurosurg Focus 2024; 56:E14. [PMID: 38691865 DOI: 10.3171/2024.2.focus2419] [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: 01/02/2024] [Accepted: 02/27/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Chordomas are locally aggressive neoplasms of the spine or skull base that arise from embryonic remnants of the notochord. Intradural chordomas represent a rare subset of these neoplasms, and few studies have described intradural chordomas in the spine. This review evaluates the presentation, management, and outcomes of intradural spinal chordomas. METHODS A systematic review of PubMed/MEDLINE, EMBASE, Cochrane Library, Scopus, and Web of Science was performed. Studies describing at least 1 case of intradural chordomas anywhere in the spine were included. Extracted details included presenting symptoms, radiological findings, treatment course, follow-up, and disease progression. RESULTS Thirty-one studies, with a total of 41 patients, were included in this review. Seventy-six percent (31/41) of patients had primary intradural tumors, whereas 24% (10/41) presented with metastasis. The most common signs and symptoms were pain (n = 27, 66%); motor deficits (n = 20, 49%); sensory deficits (n = 17, 42%); and gait disturbance (n = 10, 24%). The most common treatment for intradural chordoma was resection and postoperative radiotherapy. Sixty-six percent (19/29) of patients reported improvement or complete resolution of symptoms after surgery. The recurrence rate was 37% (10/27), and the complication rate was 25% (6/24). The median progression-free survival was 24 months (range 4-72 months). Four patient deaths were reported. The median follow-up time was 12 months (range 13 days-84 months). CONCLUSIONS Treatment of intradural spinal chordomas primarily involves resection and radiotherapy. A significant challenge and complication in management is spinal tumor seeding after resection, with 9 studies proposing seeding as a mechanism of tumor metastasis in 11 cases. Factors such as tumor size, Ki-67 positivity, and distant metastasis may correlate with worse outcomes and demonstrate potential as prognostic indicators for intradural spinal chordomas. Further research is needed to improve understanding of this tumor and develop optimal treatment paradigms for these patients.
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Affiliation(s)
| | | | | | | | | | | | - Sang H Lee
- 3Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Davidar AD, Jiang K, Weber-Levine C, Bhimreddy M, Theodore N. Advancements in Robotic-Assisted Spine Surgery. Neurosurg Clin N Am 2024; 35:263-272. [PMID: 38423742 DOI: 10.1016/j.nec.2023.11.005] [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] [Indexed: 03/02/2024]
Abstract
Applications and workflows around spinal robotics have evolved since these systems were first introduced in 2004. Initially approved for lumbar pedicle screw placement, the scope of robotics has expanded to instrumentation across different regions. Additionally, precise navigation can aid in tumor resection or spinal lesion ablation. Robot-assisted surgery can improve accuracy while decreasing radiation exposure, length of hospital stay, complication, and revision rates. Disadvantages include increased operative time, dependence on preoperative imaging among others. The future of robotic spine surgery includes automated surgery, telerobotic surgery, and the inclusion of machine learning or artificial intelligence in preoperative planning.
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Affiliation(s)
- A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghana Bhimreddy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Orthopaedic Surgery & Biomedical Engineering, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Vattipally VN, Jiang K, Weber-Levine C, Rosin R, Davidar AD, Hersh AM, Khalifeh J, Ahmed AK, Azad TD, Ashayeri K, Lubelski D, Mukherjee D, Huang J, Theodore N. Exoscope Use in Spine Surgery: A Systematic Review of Applications, Benefits, and Limitations. World Neurosurg 2024; 184:283-292.e3. [PMID: 38154686 DOI: 10.1016/j.wneu.2023.12.102] [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: 10/31/2023] [Revised: 12/18/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. METHODS A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. RESULTS A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. CONCLUSIONS Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies.
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Affiliation(s)
- Vikas N Vattipally
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Richard Rosin
- Department of Neurosurgery, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York, USA
| | - A Daniel Davidar
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew M Hersh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jawad Khalifeh
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Karim Ahmed
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Tej D Azad
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kimberly Ashayeri
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel Lubelski
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debraj Mukherjee
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Jiang K, Weber-Levine C, Theodore N. In Reply: Learning Curves for Robot-Assisted Pedicle Screw Placement: Analysis of Operative Time for 234 Cases. Oper Neurosurg (Hagerstown) 2024; 26:489. [PMID: 38330387 DOI: 10.1227/ons.0000000000001084] [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: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 02/10/2024] Open
Affiliation(s)
- Kelly Jiang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Hersh AM, Weber-Levine C, Jiang K, Theodore N. Spinal Cord Injury: Emerging Technologies. Neurosurg Clin N Am 2024; 35:243-251. [PMID: 38423740 DOI: 10.1016/j.nec.2023.10.001] [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] [Indexed: 03/02/2024]
Abstract
The mainstay of treatment for spinal cord injury includes decompressive laminectomy and elevation of mean arterial pressure. However, outcomes often remain poor. Extensive research and ongoing clinical trials seek to design new treatment options for spinal cord injury, including stem cell therapy, scaffolds, brain-spine interfaces, exoskeletons, epidural electrical stimulation, ultrasound, and cerebrospinal fluid drainage. Some of these treatments are targeted at the initial acute window of injury, during which secondary damage occurs; others are designed to help patients living with chronic injuries.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA. https://twitter.com/AndrewMHersh
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA. https://twitter.com/kellyjjiang
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 7-113, Baltimore, MD 21287, USA; Orthopaedic Surgery & Biomedical Engineering, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Vattipally VN, Ahmadi S, Weber-Levine C, Liu A, Abu-Bonsrah N, Khalifeh J, Rincon-Torroella J, Bydon A. Resection of an incidentally discovered spinal arachnoid web: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23701. [PMID: 38467042 PMCID: PMC10936941 DOI: 10.3171/case23701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/16/2024] [Indexed: 03/13/2024]
Abstract
BACKGROUND Spinal arachnoid webs (SAWs) are rare pathologies of the spinal meninges often associated with syringomyelia and the radiographic "scalpel sign." Patients can experience pain, numbness, gait disturbances, or no symptoms at all. They are typically diagnosed via magnetic resonance imaging and treated with laminectomy and excision. OBSERVATIONS A 61-year-old male presented after a mechanical fall and had an incidentally discovered SAW on imaging. He was initially asymptomatic and was therefore conservatively managed. Several years later, however, the patient experienced new-onset back pain, paresthesia, and balance problems, with interval imaging demonstrating worsening of the edema surrounding his SAW. The patient subsequently underwent resection of the SAW, which led to significant resolution of his symptoms. LESSONS An SAW can be asymptomatic or can manifest with a wide variety of symptoms. When this condition is incidentally discovered in asymptomatic patients, neurosurgeons should guide these patients to follow-up urgently if they develop any neurological symptoms. At that time, further imaging can be performed to determine if surgical treatment is indicated. Although SAW is rare, clinicians should be aware of the signs and symptoms, because prompt surgical intervention can significantly improve neurological symptoms.
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Sattari SA, Antar A, Theodore JN, Hersh AM, Al-Mistarehi AH, Davidar AD, Weber-Levine C, Azad TD, Yang W, Feghali J, Xu R, Manbachi A, Lubelski D, Bettegowda C, Chang L, Witham T, Belzberg A, Theodore N. Early versus late surgical decompression for patients with acute traumatic central cord syndrome: a systematic review and meta-analysis. Spine J 2024; 24:435-445. [PMID: 37890727 DOI: 10.1016/j.spinee.2023.10.013] [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: 09/01/2023] [Revised: 10/08/2023] [Accepted: 10/22/2023] [Indexed: 10/29/2023]
Abstract
BACKGROUND CONTEXT The optimal decompression time for patients presenting with acute traumatic central cord syndrome (ATCCS) has been debated, and a high level of evidence is lacking. PURPOSE To compare early (<24 hours) versus late (≥24 hours) surgical decompression for ATCCS. STUDY DESIGN Systematic review and meta-analysis. METHODS Medline, PubMed, Embase, and CENTRAL were searched from inception to March 15th, 2023. The primary outcome was American Spinal Injury Association (ASIA) motor score. Secondary outcomes were venous thromboembolism (VTE), total complications, overall mortality, hospital length of stay (LOS), and ICU LOS. The GRADE approach determined certainty in evidence. RESULTS The nine studies included reported on 5,619 patients, of whom 2,099 (37.35%) underwent early decompression and 3520 (62.65%) underwent late decompression. The mean age (53.3 vs 56.2 years, p=.505) and admission ASIA motor score (mean difference [MD]=-0.31 [-3.61, 2.98], p=.85) were similar between the early and late decompression groups. At 6-month follow-up, the two groups were similar in ASIA motor score (MD= -3.30 [-8.24, 1.65], p=.19). However, at 1-year follow-up, the early decompression group had a higher ASIA motor score than the late decompression group in total (MD=4.89 [2.89, 6.88], p<.001, evidence: moderate), upper extremities (MD=2.59 [0.82, 4.36], p=.004) and lower extremities (MD=1.08 [0.34, 1.83], p=.004). Early decompression was also associated with lower VTE (odds ratio [OR]=0.41 [0.26, 0.65], p=.001, evidence: moderate), total complications (OR=0.53 [0.42, 0.67], p<.001, evidence: moderate), and hospital LOS (MD=-2.94 days [-3.83, -2.04], p<.001, evidence: moderate). Finally, ICU LOS (MD=-0.69 days [-1.65, 0.28], p=.16, evidence: very low) and overall mortality (OR=1.35 [0.93, 1.94], p=.11, evidence: moderate) were similar between the two groups. CONCLUSIONS The meta-analysis of these studies demonstrated that early decompression was beneficial in terms of ASIA motor score, VTE, complications, and hospital LOS. Furthermore, early decompression did not increase mortality odds. Although treatment decision-making has been individualized, early decompression should be considered for patients presenting with ATCCS, provided that the surgeon deems it appropriate.
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Affiliation(s)
- Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
| | - Albert Antar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - John N Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Abdel-Hameed Al-Mistarehi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Amir Manbachi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Louis Chang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Timothy Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Allan Belzberg
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
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Awosika T, Davidar AD, Hersh AM, Menta A, Weber-Levine C, Alomari S, Khan MA, Theodore N. SPECT/CT and PET/CT for the Evaluation of Persistent or Recurrent Pain After Spine Surgery: A Systematic Review and Case Series. World Neurosurg 2024; 182:e344-e359. [PMID: 38013108 DOI: 10.1016/j.wneu.2023.11.108] [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: 10/06/2023] [Revised: 11/21/2023] [Accepted: 11/22/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery. METHODS A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies. RESULTS A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine. CONCLUSIONS PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging.
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Affiliation(s)
- Tolulope Awosika
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Arjun Menta
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Majid Aziz Khan
- Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Ahmedna T, Khela H, Weber-Levine C, Azad TD, Jackson CM, Gabrielson K, Bettegowda C, Rincon-Torroella J. The Role of γδ T-Lymphocytes in Glioblastoma: Current Trends and Future Directions. Cancers (Basel) 2023; 15:5784. [PMID: 38136330 PMCID: PMC10741533 DOI: 10.3390/cancers15245784] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Cell-based immunotherapy for glioblastoma (GBM) encounters major challenges due to the infiltration-resistant and immunosuppressive tumor microenvironment (TME). γδ T cells, unconventional T cells expressing the characteristic γδ T cell receptor, have demonstrated promise in overcoming these challenges, suggesting great immunotherapeutic potential. This review presents the role of γδ T cells in GBM and proposes several research avenues for future studies. Using the PubMed, ScienceDirect, and JSTOR databases, we performed a review of the literature studying the biology of γδ T cells and their role in GBM treatment. We identified 15 studies focused on γδ T cells in human GBM. Infiltrative γδ T cells can incite antitumor immune responses in certain TMEs, though rapid tumor progression and TME hypoxia may impact the extent of tumor suppression. In the studies, available findings have shown both the potential for robust antitumor activity and the risk of protumor activity. While γδ T cells have potential as a therapeutic agent against GBM, the technical challenges of extracting, isolating, and expanding γδ T cells, and the activation of antitumoral versus protumoral cascades, remain barriers to their application. Overcoming these limitations may transform γδ T cells into a promising immunotherapy in GBM.
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Affiliation(s)
- Taha Ahmedna
- Department of Biology, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Harmon Khela
- Department of Biology, Johns Hopkins University, Baltimore, MD 21287, USA
- Department of Public Health Studies, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Tej D. Azad
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Christopher M. Jackson
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Kathleen Gabrielson
- Department of Molecular and Comparative Pathobiology and Oncology, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Chetan Bettegowda
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Jordina Rincon-Torroella
- Department of Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD 21287, USA
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10
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Jiang K, Hersh AM, Bhimreddy M, Weber-Levine C, Davidar AD, Menta AK, Routkevitch D, Alomari S, Judy BF, Lubelski D, Weingart J, Theodore N. Learning Curves for Robot-Assisted Pedicle Screw Placement: Analysis of Operative Time for 234 Cases. Oper Neurosurg (Hagerstown) 2023; 25:482-488. [PMID: 37578266 DOI: 10.1227/ons.0000000000000862] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 03/14/2023] [Accepted: 06/07/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Robot-assisted pedicle screw placement is associated with greater accuracy, reduced radiation, less blood loss, shorter hospital stays, and fewer complications than freehand screw placement. However, it can be associated with longer operative times and an extended training period. We report the initial experience of a surgeon using a robot system at an academic medical center. METHODS We retrospectively reviewed all patients undergoing robot-assisted pedicle screw placement at a single tertiary care institution by 1 surgeon from 10/2017 to 05/2022. Linear regression, analysis of variance, and cumulative sum analysis were used to evaluate operative time learning curves. Operative time subanalyses for surgery indication, number of levels, and experience level were performed. RESULTS In total, 234 cases were analyzed. A significant 0.19-minute decrease in operative time per case was observed (r = 0.14, P = .03). After 234 operations, this translates to a reduction in 44.5 minutes from the first to last case. A linear relationship was observed between case number and operative time in patients with spondylolisthesis (-0.63 minutes/case, r = 0.41, P < .001), 2-level involvement (-0.35 minutes/case, r = 0.19, P = .05), and 4-or-more-level involvement (-1.29 minutes/case, r = 0.24, P = .05). This resulted in reductions in operative time ranging from 39 minutes to 1.5 hours. Continued reductions in operative time were observed across the learning, experienced, and expert phases, which had mean operative times of 214, 197, and 146 minutes, respectively ( P < .001). General proficiency in robot-assisted surgery was observed after the 20th case. However, 67 cases were required to reach mastery, defined as the inflection point of the cumulative sum curve. CONCLUSION This study documents the long-term learning curve of a fellowship-trained spine neurosurgeon. Operative time significantly decreased with more experience. Although gaining comfort with robotic systems may be challenging or require additional training, it can benefit surgeons and patients alike with continued reductions in operative time.
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Affiliation(s)
- Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Davidar AD, Judy BF, Hersh AM, Weber-Levine C, Alomari S, Menta AK, Jiang K, Bhimreddy M, Hussain M, Crawford NR, Khan M, Gong G, Theodore N. Robot-assisted screw fixation in a cadaver utilizing magnetic resonance imaging-based synthetic computed tomography: toward radiation-free spine surgery. Illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23120. [PMID: 37458340 PMCID: PMC10555644 DOI: 10.3171/case23120] [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] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 05/04/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Synthetic computed tomography (sCT) can be created from magnetic resonance imaging (MRI) utilizing newer software. sCT is yet to be explored as a possible alternative to routine CT (rCT). In this study, rCT scans and MRI-derived sCT scans were obtained on a cadaver. Morphometric analysis was performed comparing the 2 scans. The ExcelsiusGPS robot was used to place lumbosacral screws with both rCT and sCT images. OBSERVATIONS In total, 14 screws were placed. All screws were grade A on the Gertzbein-Robbins scale. The mean surface distance difference between rCT and sCT on a reconstructed software model was -0.02 ± 0.05 mm, the mean absolute surface distance was 0.24 ± 0.05 mm, and the mean absolute error of radiodensity was 92.88 ± 10.53 HU. The overall mean tip distance for the sCT versus rCT was 1.74 ± 1.1 versus 2.36 ± 1.6 mm (p = 0.24); mean tail distance for the sCT versus rCT was 1.93 ± 0.88 versus 2.81 ± 1.03 mm (p = 0.07); and mean angular deviation for the sCT versus rCT was 3.2° ± 2.05° versus 4.04°± 2.71° (p = 0.53). LESSONS MRI-based sCT yielded results comparable to those of rCT in both morphometric analysis and robot-assisted lumbosacral screw placement in a cadaver study.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Majid Khan
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
| | - Gary Gong
- Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Tsehay Y, Zeng Y, Weber-Levine C, Awosika T, Kerensky M, Hersh AM, Ou Z, Jiang K, Bhimreddy M, Bauer SJ, Theodore JN, Quiroz VM, Suk I, Alomari S, Sun J, Tong S, Thakor N, Doloff JC, Theodore N, Manbachi A. Low-Intensity Pulsed Ultrasound Neuromodulation of a Rodent's Spinal Cord Suppresses Motor Evoked Potentials. IEEE Trans Biomed Eng 2023; 70:1992-2001. [PMID: 37018313 PMCID: PMC10510849 DOI: 10.1109/tbme.2022.3233345] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Here we investigate the ability of low-intensity ultrasound (LIUS) applied to the spinal cord to modulate the transmission of motor signals. METHODS Male adult Sprague-Dawley rats (n = 10, 250-300 g, 15 weeks old) were used in this study. Anesthesia was initially induced with 2% isoflurane carried by oxygen at 4 L/min via a nose cone. Cranial, upper extremity, and lower extremity electrodes were placed. A thoracic laminectomy was performed to expose the spinal cord at the T11 and T12 vertebral levels. A LIUS transducer was coupled to the exposed spinal cord, and motor evoked potentials (MEPs) were acquired each minute for either 5- or 10-minutes of sonication. Following the sonication period, the ultrasound was turned off and post-sonication MEPs were acquired for an additional 5 minutes. RESULTS Hindlimb MEP amplitude significantly decreased during sonication in both the 5- (p < 0.001) and 10-min (p = 0.004) cohorts with a corresponding gradual recovery to baseline. Forelimb MEP amplitude did not demonstrate any statistically significant changes during sonication in either the 5- (p = 0.46) or 10-min (p = 0.80) trials. CONCLUSION LIUS applied to the spinal cord suppresses MEP signals caudal to the site of sonication, with recovery of MEPs to baseline after sonication. SIGNIFICANCE LIUS can suppress motor signals in the spinal cord and may be useful in treating movement disorders driven by excessive excitation of spinal neurons.
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13
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Judy BF, Materi J, Lee RP, Tracz JA, Patel J, Weber-Levine C, Crigger C, Mistry P, Gearhart JP, Jackson EM. Spinal dysraphism in exstrophy: a single-center study of a 39-year prospective database. J Neurosurg Pediatr 2023; 32:98-105. [PMID: 37119103 DOI: 10.3171/2023.3.peds22447] [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: 10/05/2022] [Accepted: 03/20/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE The two main objectives of this study were to explore the rate of spinal dysraphism within bladder and cloacal exstrophy and to analyze the relationship between spinal dysraphism surgery, including timing of spinal dysraphism surgery, with urological and neurological outcomes. METHODS A prospectively maintained IRB-approved database of pediatric exstrophy patients treated from 1982 to 2021 was retrospectively reviewed for patients with spinal dysraphism. Spinal dysraphism was categorized into the following 7 subtypes: lipoma-based closed defect, myelomeningocele, meningocele, diastematomyelia, myelocystocele, low-lying conus with tethered cord/fatty filum, and sacral bony defect. Other factors assessed included patient demographic characteristics, type of spinal dysraphism procedure, reoperation, complication, presence of other neurological problems (e.g., hydrocephalus, Chiari malformation), neurological status, and urological function. RESULTS Analysis revealed that 114/1401 patients had coexisting spinal dysraphism. Of these 114, sufficient records including type of dysraphism were available for 54. Spinal dysraphism was most common within cloacal exstrophy (83.3% [45/54 patients]), followed by cloacal exstrophy variants (9.3% [5/54]), classic bladder exstrophy (3.7% [2/54]), and classic bladder exstrophy variants (3.7% [2/54]). Within spinal dysraphism, lipoma-based closed defects (63.0% [34/54]) and low-lying conus with tethered cord/fatty filum (11.1% [6/54]) were most common. Hydrocephalus and Chiari malformation occurred in 24.1% (13/54) and 11.1% (6/54) of patients. All 13 patients with hydrocephalus underwent shunt placement. Among those who underwent neurosurgical intervention, the complication rate for spinal dysraphism was 14.6% (7/48). Motor function data were available for 41 patients and revealed that motor function declined for 2/41 (4.8%) patients and improved for 6/41 (14.6%) after neurosurgery. There was no statistical difference in lower-extremity motor outcome related to timing of neurosurgery and exstrophy closure. CONCLUSIONS The authors have reported the surgical management and outcomes of patients with exstrophy and coexisting spinal dysraphism (n = 54). In 54 patients, spinal dysraphism was most common in the subset of patients with cloacal exstrophy (83.3%). Lipoma-based closed defects (63.0%) and low-lying conus with tethered cord/fatty filum (11.1%) were the most common, and the rates of hydrocephalus and Chiari malformation were 24.1% and 11.1%, respectively. There was no difference in lower-extremity motor outcome related to timing of neurosurgery and exstrophy closure.
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Affiliation(s)
| | | | | | | | | | | | - Chad Crigger
- 2Urology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Preeya Mistry
- 2Urology, Johns Hopkins Hospital, Baltimore, Maryland
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Hersh AM, Jin Y, Xu R, Davidar AD, Weber-Levine C, Gonzalez LF, Theodore N. Transpedicular Onyx embolization of a thoracic hemangioma with robotic assistance: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE2348. [PMID: 38015021 PMCID: PMC10550547 DOI: 10.3171/case2348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 03/06/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Hemangiomas are common benign vascular lesions that rarely present with pain and neurological deficits. Symptomatic lesions are often treated with endovascular embolization. However, transarterial embolization can be technically challenging depending on the size and caliber of the vessels. Moreover, embolization can result in osteonecrosis and vertebral collapse. OBSERVATIONS Here the authors report the first case of a T10 vertebral hemangioma treated with transpedicular Onyx embolization aided by a robotic platform that guided pedicle cannulation and Craig needle placement. An intravenous catheter was attached to the needle and dimethylsulfoxide was infused, followed by Onyx under real-time fluoroscopy. Repeat angiography demonstrated significantly reduced contrast opacification of the vertebral body without compromise of the segmental artery. A T9-11 pedicle screw fixation was performed to optimize long-term stability. The patient's symptoms improved and was stable at the 6-month follow-up. LESSONS Transpedicular embolization of vertebral hemangiomas can be performed successfully under robotic navigation guidance, avoiding complications seen with the intra-arterial approach and allowing for simultaneous pedicle screw fixation to prevent collapse and delayed kyphotic deformity. During the same procedure, a biopsy specimen can be collected for pathology. This technique can help to alleviate patient symptoms while avoiding complications associated with transarterial embolization or open resection.
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15
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Bhimreddy M, Routkevitch D, Hersh AM, Mohammadabadi A, Menta AK, Jiang K, Weber-Levine C, Davidar AD, Punnoose J, Kempski Leadingham KM, Doloff JC, Tyler B, Theodore N, Manbachi A. Disruption of the Blood-Spinal Cord Barrier using Low-Intensity Focused Ultrasound in a Rat Model. J Vis Exp 2023:10.3791/65113. [PMID: 36971451 PMCID: PMC10986840 DOI: 10.3791/65113] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Low-intensity focused ultrasound (LIFU) uses ultrasonic pulsations at lower intensities than ultrasound and is being tested as a reversible and precise neuromodulatory technology. Although LIFU-mediated blood-brain barrier (BBB) opening has been explored in detail, no standardized technique for blood-spinal cord barrier (BSCB) opening has been established to date. Therefore, this protocol presents a method for successful BSCB disruption using LIFU sonication in a rat model, including descriptions of animal preparation, microbubble administration, target selection and localization, as well as BSCB disruption visualization and confirmation. The approach reported here is particularly useful for researchers who need a fast and cost-effective method to test and confirm target localization and precise BSCB disruption in a small animal model with a focused ultrasound transducer, evaluate the BSCB efficacy of sonication parameters, or explore applications for LIFU at the spinal cord, such as drug delivery, immunomodulation, and neuromodulation. Optimizing this protocol for individual use is recommended, especially for advancing future preclinical, clinical, and translational work.
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Affiliation(s)
- Meghana Bhimreddy
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Denis Routkevitch
- Department of Neurosurgery, Johns Hopkins University School of Medicine; Department of Biomedical Engineering, Johns Hopkins University; HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Ali Mohammadabadi
- Department of Neurosurgery, Johns Hopkins University School of Medicine; HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine
| | - Arjun K Menta
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | | | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Joshua Punnoose
- Department of Neurosurgery, Johns Hopkins University School of Medicine; Department of Biomedical Engineering, Johns Hopkins University; HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine
| | - Kelley M Kempski Leadingham
- Department of Neurosurgery, Johns Hopkins University School of Medicine; HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine
| | - Joshua C Doloff
- Department of Biomedical Engineering, Johns Hopkins University
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine; HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine
| | - Amir Manbachi
- Department of Neurosurgery, Johns Hopkins University School of Medicine; Department of Biomedical Engineering, Johns Hopkins University; HEPIUS Innovation Laboratory, Johns Hopkins University School of Medicine; Department of Electrical Engineering and Computer Science, Johns Hopkins University; Department of Mechanical Engineering, Johns Hopkins University; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University;
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Mao G, Kopparapu S, Jin Y, Davidar AD, Hersh AM, Weber-Levine C, Theodore N. Craniocervical instability in patients with Ehlers-Danlos syndrome: controversies in diagnosis and management. Spine J 2022; 22:1944-1952. [PMID: 36028216 DOI: 10.1016/j.spinee.2022.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 05/18/2022] [Revised: 08/02/2022] [Accepted: 08/17/2022] [Indexed: 02/03/2023]
Abstract
Ehlers-Danlos syndrome (EDS) is a rare hereditary condition that can result in ligamentous laxity and hypermobility of the cervical spine. A subset of patients can develop clinical instability of the craniocervical junction associated with pain and neurological dysfunction, potentially warranting treatment with occipitocervical fixation (OCF). Surgical decision-making in patients with EDS can be complicated by difficulty distinguishing from hypermobility inherent in the disease and true pathological instability necessitating intervention. Here we comprehensively review the available medical literature to critically appraise the evidence behind various proposed definitions of instability in the EDS population, and summarize the available outcomes data after OCF. Several radiographic parameters have been used, including the clivo-axial angle, basion-axial interval, and pB-C2 measurement. Despite increasing recognition of EDS by spine surgeons, there remains a paucity of data supporting proposed radiographic parameters for spinal instability among EDS patients. Furthermore, there is a lack of high-quality evidence concerning the efficacy of surgical treatments for chronic debilitating pain prevalent in this population. More standardized clinical measures and rigorous study methodologies are needed to elucidate the role of surgical intervention in this complex patient population.
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Affiliation(s)
- Gordon Mao
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Srujan Kopparapu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Yike Jin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, , 600 N. Wolfe St., Meyer 7-113, Baltimore, MD 21287, USA.
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Weber-Levine C, Judy BF, Hersh AM, Awosika T, Tsehay Y, Kim T, Chara A, Theodore N. Multimodal interventions to optimize spinal cord perfusion in patients with acute traumatic spinal cord injuries: a systematic review. J Neurosurg Spine 2022; 37:729-739. [PMID: 35901776 DOI: 10.3171/2022.4.spine211434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 04/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors systematically reviewed current evidence for the utility of mean arterial pressure (MAP), intraspinal pressure (ISP), and spinal cord perfusion pressure (SCPP) as predictors of outcomes after traumatic spinal cord injury (SCI). METHODS PubMed, Cochrane Reviews Library, EMBASE, and Scopus databases were queried in December 2020. Two independent reviewers screened articles using Covidence software. Disagreements were resolved by a third reviewer. The inclusion criteria for articles were 1) available in English; 2) full text; 3) clinical studies on traumatic SCI interventions; 4) involved only human participants; and 5) focused on MAP, ISP, or SCPP. Exclusion criteria were 1) only available in non-English languages; 2) focused only on the brain; 3) described spinal diseases other than SCI; 4) interventions altering parameters other than MAP, ISP, or SCPP; and 5) animal studies. Studies were analyzed qualitatively and grouped into two categories: interventions increasing MAP or interventions decreasing ISP. The Scottish Intercollegiate Guidelines Network level of evidence was used to assess bias and the Grading of Recommendations, Assessment, Development, and Evaluation approach was used to rate confidence in the anticipated effects of each outcome. RESULTS A total of 2540 unique articles were identified, of which 72 proceeded to full-text review and 24 were included in analysis. One additional study was included retrospectively. Articles that went through full-text review were excluded if they were a review paper (n = 12), not a full article (n = 12), a duplicate paper (n = 9), not a human study (n = 3), not in English (n = 3), not pertaining to traumatic SCI (n = 3), an improper intervention (n = 3), without intervention (n = 2), and without analysis of intervention (n = 1). Although maintaining optimal MAP levels is the current recommendation for SCI management, the published literature supports maintenance of SCPP as a stronger indicator of favorable outcomes. Studies also suggest that laminectomy and durotomy may provide better outcomes than laminectomy alone, although higher-level studies are needed. Current evidence is inconclusive on the effectiveness of CSF drainage for reducing ISP. CONCLUSIONS This review demonstrates the importance of assessing how different interventions may vary in their ability to optimize SCPP.
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Hersh AM, Bhimreddy M, Weber-Levine C, Jiang K, Alomari S, Theodore N, Manbachi A, Tyler BM. Applications of Focused Ultrasound for the Treatment of Glioblastoma: A New Frontier. Cancers (Basel) 2022; 14:cancers14194920. [PMID: 36230843 PMCID: PMC9563027 DOI: 10.3390/cancers14194920] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/21/2022] Open
Abstract
Simple Summary Glioblastoma (GBM) is a common primary brain tumor with a short median overall survival despite aggressive treatment with resection, chemotherapy, and radiation therapy. Focused ultrasound (FUS) represents a promising new therapeutic approach for treatment of GBM. Unlike imaging forms of ultrasound, FUS can successfully penetrate the skull surrounding the brain, allowing for non-invasive ablation of tumor tissue. FUS can also temporarily disrupt the blood–brain barrier, a microvascular network that prohibits diffusion of most therapeutic agents, allowing chemotherapeutic drugs to penetrate the tumor. Other modalities are under investigation and include means of stimulating the immune system and sensitizing tumors to radiation therapy. The feasibility and safety of transcranial FUS has been illustrated in animal models and clinical trials. Precise results can be obtained under guidance from magnetic resonance imaging, limiting side effects. Successful outcomes from clinical trials will likely continue to motivate investigation and innovation of FUS technology for GBM. Abstract Glioblastoma (GBM) is an aggressive primary astrocytoma associated with short overall survival. Treatment for GBM primarily consists of maximal safe surgical resection, radiation therapy, and chemotherapy using temozolomide. Nonetheless, recurrence and tumor progression is the norm, driven by tumor stem cell activity and a high mutational burden. Focused ultrasound (FUS) has shown promising results in preclinical and clinical trials for treatment of GBM and has received regulatory approval for the treatment of other neoplasms. Here, we review the range of applications for FUS in the treatment of GBM, which depend on parameters, including frequency, power, pulse duration, and duty cycle. Low-intensity FUS can be used to transiently open the blood–brain barrier (BBB), which restricts diffusion of most macromolecules and therapeutic agents into the brain. Under guidance from magnetic resonance imaging, the BBB can be targeted in a precise location to permit diffusion of molecules only at the vicinity of the tumor, preventing side effects to healthy tissue. BBB opening can also be used to improve detection of cell-free tumor DNA with liquid biopsies, allowing non-invasive diagnosis and identification of molecular mutations. High-intensity FUS can cause tumor ablation via a hyperthermic effect. Additionally, FUS can stimulate immunological attack of tumor cells, can activate sonosensitizers to exert cytotoxic effects on tumor tissue, and can sensitize tumors to radiation therapy. Finally, another mechanism under investigation, known as histotripsy, produces tumor ablation via acoustic cavitation rather than thermal effects.
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Affiliation(s)
- Andrew M. Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Meghana Bhimreddy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Amir Manbachi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Mechanical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Electrical and Computer Engineering, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Betty M. Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence: ; Tel.: +1-410-502-8197
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Hersh AM, Weber-Levine C, Jiang K, Young L, Kerensky M, Routkevitch D, Tsehay Y, Perdomo-Pantoja A, Judy BF, Lubelski D, Theodore N, Manbachi A. Applications of elastography in operative neurosurgery: A systematic review. J Clin Neurosci 2022; 104:18-28. [PMID: 35933785 PMCID: PMC11023619 DOI: 10.1016/j.jocn.2022.07.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 07/06/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
Elastography is an imaging technology capable of measuring tissue stiffness and consistency. The technology has achieved widespread use in the workup and management of diseases of the liver, breast, thyroid, and prostate. Although elastography is increasingly being applied in neurosurgery, it has not yet achieved widespread adoption and many clinicians remain unfamiliar with the technology. Therefore, we sought to summarize the range of applications and elastography modalities available for neurosurgery, report its effectiveness in comparison with conventional imaging methods, and offer recommendations. All full-text English-language manuscripts on the use of elastography for neurosurgical procedures were screened using the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science databases. Thirty-two studies were included with 990 patients, including 21 studies on intracranial tumors, 5 on hydrocephalus, 4 on epilepsy, 1 on spinal cord compression, and 1 on adolescent scoliosis. Twenty studies used ultrasound elastography (USE) whereas 12 used magnetic resonance elastography (MRE). MRE studies were mostly used in the preoperative setting for assessment of lesion stiffness, tumor-brain adherence, diagnostic workup, and operative planning. USE studies were performed intraoperatively to guide resection of lesions, determine residual microscopic abnormalities, assess the tumor-brain interface, and study mechanical properties of tumors. Elastography can assist with resection of brain tissue, detection of microscopic lesions, and workup of hydrocephalus, among other applications under investigation. Its sensitivity often exceeds that of conventional MRI and ultrasound for identifying abnormal tissue and lesion margins.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lisa Young
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Max Kerensky
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Denis Routkevitch
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Yohannes Tsehay
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | | | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Amir Manbachi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Hersh AM, Davidar AD, Weber-Levine C, Raj D, Alomari S, Judy BF, Theodore N. Advancements in the treatment of traumatic spinal cord injury during military conflicts. Neurosurg Focus 2022; 53:E15. [DOI: 10.3171/2022.6.focus22262] [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: 04/30/2022] [Accepted: 06/15/2022] [Indexed: 11/06/2022]
Abstract
Significant advancements in the treatment of spinal cord injury (SCI) were developed in the setting of military conflicts, partly due to the large numbers of injuries sustained by service members. No effective SCI treatment options existed into the early 20th century, and soldiers who sustained these injuries were usually considered untreatable. Extensive progress was made in SCI treatment during and after World War II, as physical therapy was increasingly encouraged for patients with SCI, multidisciplinary teams oversaw care, pathophysiology was better understood, and strategies were devised to prevent wound infection and pressure sores. Recent conflicts in Iraq and Afghanistan have caused a substantial rise in the proportion of SCIs among causes of casualties and wounds, largely due to new forms of war and weapons, such as improvised explosive devices. Modern military SCIs resulting from blast mechanisms are substantively different from traumatic SCIs sustained by civilians. The treatment paradigms developed over the past 100 years have increased survival rates and outcomes of soldiers with SCI. In this paper, the authors review the role of military conflicts in the development of therapeutic interventions for SCI and discuss how these interventions have improved outcomes for soldiers and civilians alike.
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Affiliation(s)
- Andrew M. Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - A. Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Divyaansh Raj
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brendan F. Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Weber-Levine C, Hersh AM, Jiang K, Routkevitch D, Tsehay Y, Perdomo-Pantoja A, Judy BF, Kerensky M, Liu A, Adams M, Izzi J, Doloff JC, Manbachi A, Theodore N. Porcine Model of Spinal Cord Injury: A Systematic Review. Neurotrauma Rep 2022; 3:352-368. [PMID: 36204385 PMCID: PMC9531891 DOI: 10.1089/neur.2022.0038] [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] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Spinal cord injury (SCI) is a devastating disease with limited effective treatment options. Animal paradigms are vital for understanding the pathogenesis of SCI and testing potential therapeutics. The porcine model of SCI is increasingly favored because of its greater similarity to humans. However, its adoption is limited by the complexities of care and range of testing parameters. Researchers need to consider swine selection, injury method, post-operative care, rehabilitation, behavioral outcomes, and histology metrics. Therefore, we systematically reviewed full-text English-language articles to evaluate study characteristics used in developing a porcine model and summarize the interventions that have been tested using this paradigm. A total of 63 studies were included, with 33 examining SCI pathogenesis and 30 testing interventions. Studies had an average sample size of 15 pigs with an average weight of 26 kg, and most used female swine with injury to the thoracic cord. Injury was most commonly induced by weight drop with compression. The porcine model is amenable to testing various interventions, including mean arterial pressure augmentation (n = 7), electrical stimulation (n = 6), stem cell therapy (n = 5), hypothermia (n = 2), biomaterials (n = 2), gene therapy (n = 2), steroids (n = 1), and nanoparticles (n = 1). It is also notable for its clinical translatability and is emerging as a valuable pre-clinical study tool. This systematic review can serve as a guideline for researchers implementing and testing the porcine SCI model.
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Affiliation(s)
- Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew M. Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Denis Routkevitch
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yohannes Tsehay
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Brendan F. Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Max Kerensky
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ann Liu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Melanie Adams
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jessica Izzi
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joshua C. Doloff
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Amir Manbachi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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22
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Perdomo-Pantoja A, Zakaria HM, Liu A, Tsehay Y, Weber-Levine C, Mao G, Theodore N. Vascular Myelopathy Secondary to Compression of the Artery of Adamkiewicz From an Intrathecal Catheter: A Technical Case Report. Oper Neurosurg (Hagerstown) 2022; 23:e143-e146. [PMID: 35838478 DOI: 10.1227/ons.0000000000000258] [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: 12/13/2021] [Accepted: 03/03/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Although catheter-related complications in intrathecal drug delivery systems are relatively common, vascular myelopathy secondary to occlusion of the artery of Adamkiewicz (AoA) from an abutting intrathecal catheter has not yet been reported. In this study, we present a case of this extremely rare presentation, which resolved after decompression of the artery. CLINICAL PRESENTATION A 39-year-old woman presented with lower extremity weakness and paresthesia. She had a 20-year history of severe chronic back pain and stable sensory disturbances below T8 as sequelae of multiple injuries after a motor vehicle accident. Three years before presentation in our clinic, she underwent baclofen pump placement because of neuropathic pain refractory to oral medication. After pump placement, she gradually developed myelopathic symptoms and dysautonomia. All medications through the pump were discontinued, but her symptoms continued to progress. Workup included a spinal angiogram that showed that her intrathecal catheter was abutting the left side of the AoA at the T12 level. After interdisciplinary evaluation, it was believed that her clinical presentation was attributable to vascular compression, and she underwent surgical removal of the catheter. Three years later, her symptoms have improved and her neurological examination returned to baseline before the catheter placement. CONCLUSION Meticulous, multidisciplinary neurological and radiological evaluations were essential to diagnose the compression of the AoA as the cause of this patient's myelopathy. Although exceedingly rare, direct compression of the AoA by an intrathecal catheter should be on the differential diagnosis when evaluating for causes of vascular myelopathy.
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23
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Hwang BY, Mampre D, Tsehay YK, Negoita S, Kim MJ, Coogan C, Eremiev A, Palla A, Weber-Levine C, Kang JY, Anderson WS. Piriform Cortex Ablation Volume Is Associated With Seizure Outcome in Mesial Temporal Lobe Epilepsy. Neurosurgery 2022; 91:414-421. [PMID: 35593730 DOI: 10.1227/neu.0000000000002041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Growing evidence suggests that piriform cortex resection during anterior temporal lobectomy is important for achieving good seizure outcome in mesial temporal lobe epilepsy (mTLE). However, the relationship between seizure outcome and piriform cortex ablation during MR-guided laser interstitial thermal therapy (MRgLITT) remains unclear. OBJECTIVE To determine whether ablation of piriform cortex was associated with seizure outcome in patients with mTLE undergoing MRgLITT. METHODS We performed preablation and postablation volumetric analyses of hippocampus, amygdala, piriform cortex, and ablation volumes in patients with mTLE who underwent MRgLITT at our institution from 2014 to 2019. RESULTS Thirty nine patients with mTLE were analyzed. In univariate logistic regression, percent piriform cortex ablation was associated with International League Against Epilepsy (ILAE) class 1 at 6 months (odds ratio [OR] 1.051, 95% CI [1.001-1.117], P = .045), whereas ablation volume, percent amygdala ablation, and percent hippocampus ablation were not (P > .05). At 1 year, ablation volume was associated with ILAE class 1 (OR 1.608, 95% CI [1.071-2.571], P = .021) while percent piriform cortex ablation became a trend (OR 1.050, 95% CI [0.994-1.109], P = .054), and both percent hippocampus ablation and percent amygdala ablation were not significantly associated with ILAE class 1 (P > .05). In multivariable logistic regression, only percent piriform cortex ablation was a significant predictor of seizure freedom at 6 months (OR 1.085, 95% CI [1.012-1.193], P = .019) and at 1 year (OR 1.074, 95% CI [1.003-1.178], P = .041). CONCLUSION Piriform cortex ablation volume is associated with seizure outcome in patients with mTLE undergoing MRgLITT. The piriform cortex should be considered a high yield ablation target to achieve good seizure outcome.
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Affiliation(s)
- Brian Y Hwang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - David Mampre
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yohannes K Tsehay
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Serban Negoita
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Min Jae Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher Coogan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander Eremiev
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Adhith Palla
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joon Y Kang
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - William S Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Doerr SA, Weber-Levine C, Hersh AM, Awosika T, Judy B, Jin Y, Raj D, Liu A, Lubelski D, Jones CK, Sair HI, Theodore N. Automated prediction of the Thoracolumbar Injury Classification and Severity Score from CT using a novel deep learning algorithm. Neurosurg Focus 2022; 52:E5. [PMID: 35364582 DOI: 10.3171/2022.1.focus21745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/30/2021] [Accepted: 01/18/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans. METHODS All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the PLC were categorized on CT scans. A state-of-the-art object detection region-based convolutional neural network (R-CNN), Faster R-CNN, was leveraged to predict both vertebral locations and the corresponding TLICS. The network was trained with patient CT scans, manually labeled vertebral bounding boxes, TLICS morphology, and PLC annotations, thus allowing the model to output the location of vertebrae, categorize their morphology, and determine the status of PLC integrity. RESULTS A total of 111 patients were included (mean ± SD age 62 ± 20 years) with a total of 129 separate injury classifications. Vertebral localization and PLC integrity classification achieved Dice scores of 0.92 and 0.88, respectively. Binary classification between noninjured and injured morphological scores demonstrated 95.1% accuracy. TLICS morphology accuracy, the true positive rate, and positive injury mismatch classification rate were 86.3%, 76.2%, and 22.7%, respectively. Classification accuracy between no injury and suspected PLC injury was 86.8%, while true positive, false negative, and false positive rates were 90.0%, 10.0%, and 21.8%, respectively. CONCLUSIONS In this study, the authors demonstrate a novel deep learning method to automatically predict injury morphology and PLC disruption with high accuracy. This model may streamline and improve diagnostic decision support for patients with thoracolumbar spinal trauma.
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Affiliation(s)
- Sophia A Doerr
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Carly Weber-Levine
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Andrew M Hersh
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Tolulope Awosika
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Brendan Judy
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Yike Jin
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Divyaansh Raj
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Ann Liu
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Daniel Lubelski
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
| | - Craig K Jones
- 2Malone Center for Engineering in Healthcare, Johns Hopkins University, Baltimore; and
| | - Haris I Sair
- 3Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nicholas Theodore
- 1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore
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25
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Abstract
Augmented reality (AR) navigation refers to novel technologies that superimpose images, such as radiographs and navigation pathways, onto a view of the operative field. The development of AR navigation has focused on improving the safety and efficacy of neurosurgical and orthopedic procedures. In this review, the authors focus on 3 types of AR technology used in spine surgery: AR surgical navigation, microscope-mediated heads-up display, and AR head-mounted displays. Microscope AR and head-mounted displays offer the advantage of reducing attention shift and line-of-sight interruptions inherent in traditional navigation systems. With the U.S. Food and Drug Administration's recent clearance of the XVision AR system (Augmedics, Arlington Heights, IL), the adoption and refinement of AR technology by spine surgeons will only accelerate.
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Affiliation(s)
- Andrew Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Smruti Mahapatra
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carly Weber-Levine
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tolulope Awosika
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Hesham M Zakaria
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ann Liu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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