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Ann Liu, Yike Jin, Ethan Cottrill, Majid Khan, Erick Westbroek, Jeff Ehresman, Zach Pennington, Sheng-fu L. Lo, Daniel M. Sciubba, Camilo A. Molina, and Timothy F. Witham

OBJECTIVE

Augmented reality (AR) is a novel technology which, when applied to spine surgery, offers the potential for efficient, safe, and accurate placement of spinal instrumentation. The authors report the accuracy of the first 205 pedicle screws consecutively placed at their institution by using AR assistance with a unique head-mounted display (HMD) navigation system.

METHODS

A retrospective review was performed of the first 28 consecutive patients who underwent AR-assisted pedicle screw placement in the thoracic, lumbar, and/or sacral spine at the authors’ institution. Clinical accuracy for each pedicle screw was graded using the Gertzbein-Robbins scale by an independent neuroradiologist working in a blinded fashion.

RESULTS

Twenty-eight consecutive patients underwent thoracic, lumbar, or sacral pedicle screw placement with AR assistance. The median age at the time of surgery was 62.5 (IQR 13.8) years and the median body mass index was 31 (IQR 8.6) kg/m2. Indications for surgery included degenerative disease (n = 12, 43%); deformity correction (n = 12, 43%); tumor (n = 3, 11%); and trauma (n = 1, 4%). The majority of patients (n = 26, 93%) presented with low-back pain, 19 (68%) patients presented with radicular leg pain, and 10 (36%) patients had documented lower extremity weakness. A total of 205 screws were consecutively placed, with 112 (55%) placed in the lumbar spine, 67 (33%) in the thoracic spine, and 26 (13%) at S1. Screw placement accuracy was 98.5% for thoracic screws, 97.8% for lumbar/S1 screws, and 98.0% overall.

CONCLUSIONS

AR depicted through a unique HMD is a novel and clinically accurate technology for the navigated insertion of pedicle screws. The authors describe the first 205 AR-assisted thoracic, lumbar, and sacral pedicle screws consecutively placed at their institution with an accuracy of 98.0% as determined by a Gertzbein-Robbins grade of A or B.

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Dean Chou, Virginie Lafage, Alvin Y. Chan, Peter Passias, Gregory M. Mundis Jr., Robert K. Eastlack, Kai-Ming Fu, Richard G. Fessler, Munish C. Gupta, Khoi D. Than, Neel Anand, Juan S. Uribe, Adam S. Kanter, David O. Okonkwo, Shay Bess, Christopher I. Shaffrey, Han Jo Kim, Justin S. Smith, Daniel M. Sciubba, Paul Park, Praveen V. Mummaneni, and the International Spine Study Group (ISSG)

OBJECTIVE

Circumferential minimally invasive spine surgery (cMIS) for adult scoliosis has become more advanced and powerful, but direct comparison with traditional open correction using prospectively collected data is limited. The authors performed a retrospective review of prospectively collected, multicenter adult spinal deformity data. The authors directly compared cMIS for adult scoliosis with open correction in propensity-matched cohorts using health-related quality-of-life (HRQOL) measures and surgical parameters.

METHODS

Data from a prospective, multicenter adult spinal deformity database were retrospectively reviewed. Inclusion criteria were age > 18 years, minimum 1-year follow-up, and one of the following characteristics: pelvic tilt (PT) > 25°, pelvic incidence minus lumbar lordosis (PI-LL) > 10°, Cobb angle > 20°, or sagittal vertical axis (SVA) > 5 cm. Patients were categorized as undergoing cMIS (percutaneous screws with minimally invasive anterior interbody fusion) or open correction (traditional open deformity correction). Propensity matching was used to create two equal groups and to control for age, BMI, preoperative PI-LL, pelvic incidence (PI), T1 pelvic angle (T1PA), SVA, PT, and number of posterior levels fused.

RESULTS

A total of 154 patients (77 underwent open procedures and 77 underwent cMIS) were included after matching for age, BMI, PI-LL (mean 15° vs 17°, respectively), PI (54° vs 54°), T1PA (21° vs 22°), and mean number of levels fused (6.3 vs 6). Patients who underwent three-column osteotomy were excluded. Follow-up was 1 year for all patients. Postoperative Oswestry Disability Index (ODI) (p = 0.50), Scoliosis Research Society–total (p = 0.45), and EQ-5D (p = 0.33) scores were not different between cMIS and open patients. Maximum Cobb angles were similar for open and cMIS patients at baseline (25.9° vs 26.3°, p = 0.85) and at 1 year postoperation (15.0° vs 17.5°, p = 0.17). In total, 58.3% of open patients and 64.4% of cMIS patients (p = 0.31) reached the minimal clinically important difference (MCID) in ODI at 1 year. At 1 year, no differences were observed in terms of PI-LL (p = 0.71), SVA (p = 0.46), PT (p = 0.9), or Cobb angle (p = 0.20). Open patients had greater estimated blood loss compared with cMIS patients (1.36 L vs 0.524 L, p < 0.05) and fewer levels of interbody fusion (1.87 vs 3.46, p < 0.05), but shorter operative times (356 minutes vs 452 minutes, p = 0.003). Revision surgery rates between the two cohorts were similar (p = 0.97).

CONCLUSIONS

When cMIS was compared with open adult scoliosis correction with propensity matching, HRQOL improvement, spinopelvic parameters, revision surgery rates, and proportions of patients who reached MCID were similar between cohorts. However, well-selected cMIS patients had less blood loss, comparable results, and longer operative times in comparison with open patients.

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Chengcheng Gui, Xuguang Chen, Khadija Sheikh, Liza Mathews, Sheng-Fu L. Lo, Junghoon Lee, Majid A. Khan, Daniel M. Sciubba, and Kristin J. Redmond

OBJECTIVE

In the treatment of spinal metastases with stereotactic body radiation therapy (SBRT), vertebral compression fracture (VCF) is a common and potentially morbid complication. Better methods to identify patients at high risk of radiation-induced VCF are needed to evaluate prophylactic measures. Radiomic features from pretreatment imaging may be employed to more accurately predict VCF. The objective of this study was to develop and evaluate a machine learning model based on clinical characteristics and radiomic features from pretreatment imaging to predict the risk of VCF after SBRT for spinal metastases.

METHODS

Vertebral levels C2 through L5 containing metastases treated with SBRT were included if they were naive to prior surgery or radiation therapy, target delineation was based on consensus guidelines, and 1-year follow-up data were available. Clinical features, including characteristics of the patient, disease, and treatment, were obtained from chart review. Radiomic features were extracted from the planning target volume (PTV) on pretreatment CT and T1-weighted MRI. Clinical and radiomic features selected by least absolute shrinkage and selection operator (LASSO) regression were included in random forest classification models, which were trained to predict VCF within 1 year after SBRT. Model performance was assessed with leave-one-out cross-validation.

RESULTS

Within 1 year after SBRT, 15 of 95 vertebral levels included in the analysis demonstrated new or progressive VCF. Selected clinical features included BMI, performance status, total prescription dose, dose to 99% of the PTV, lumbar location, and 2 components of the Spine Instability Neoplastic Score (SINS): lytic tumor character and spinal misalignment. Selected radiomic features included 5 features from CT and 3 features from MRI. The best-performing classification model, derived from a combination of selected clinical and radiomic features, demonstrated a sensitivity of 0.844, specificity of 0.800, and area under the receiver operating characteristic (ROC) curve (AUC) of 0.878. This model was significantly more accurate than alternative models derived from only selected clinical features (AUC = 0.795, p = 0.048) or only components of the SINS (AUC = 0.579, p < 0.0001).

CONCLUSIONS

In the treatment of spinal metastases with SBRT, a machine learning model incorporating both clinical features and radiomic features from pretreatment imaging predicted VCF at 1 year after SBRT with excellent sensitivity and specificity, outperforming models developed from clinical features or components of the SINS alone. If validated, these findings may allow more judicious selection of patients for prophylactic interventions.

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Oluwaseun O. Akinduro, Diogo P. Garcia, Dominique M. O. Higgins, Tito Vivas-Buitrago, Mark Jentoft, David A. Solomon, David J. Daniels, Zach Pennington, Wendy J. Sherman, Mychael Delgardo, Mohamad Bydon, Maziyar A. Kalani, George Zanazzi, Nadejda Tsankova, Bernard R. Bendok, Paul C. McCormick, Daniel M. Sciubba, Sheng-fu Larry Lo, Jennifer L. Clarke, Kingsley Abode-Iyamah, and Alfredo Quiñones-Hinojosa

OBJECTIVE

High-grade spinal glioma (HGSG) is a rare but aggressive tumor that occurs in both adults and children. Histone H3 K27M mutation correlates with poor prognosis in children with diffuse midline glioma. However, the role of H3 K27M mutation in the prognosis of adults with HGSG remains unclear owing to the rarity of this mutation, conflicting reports, and the absence of multicenter studies on this topic.

METHODS

The authors studied a cohort of 30 adult patients with diffuse HGSG who underwent histological confirmation of diagnosis, surgical intervention, and treatment between January 2000 and July 2020 at six tertiary academic centers. The primary outcome was the effect of H3 K27M mutation status on progression-free survival (PFS) and overall survival (OS).

RESULTS

Thirty patients (18 males and 12 females) with a median (range) age of 50.5 (19–76) years were included in the analysis. Eighteen patients had H3 K27M mutation–positive tumors, and 12 had H3 K27M mutation–negative tumors. The median (interquartile range) PFS was 3 (10) months, and the median (interquartile range) OS was 9 (23) months. The factors associated with increased survival were treatment with concurrent chemotherapy/radiation (p = 0.006 for PFS, and p ≤ 0.001 for OS) and American Spinal Injury Association grade C or better at presentation (p = 0.043 for PFS, and p < 0.001 for OS). There were no significant differences in outcomes based on tumor location, extent of resection, sex, or H3 K27M mutation status. Analysis restricted to HGSG containing necrosis and/or microvascular proliferation (WHO grade IV histological features) revealed increased OS for patients with H3 K27M mutation–positive tumors (p = 0.017).

CONCLUSIONS

Although H3 K27M mutant–positive HGSG was associated with poor outcomes in adult patients, the outcomes of patients with H3 K27M mutant–positive HGSG were somewhat more favorable compared with those of their H3 K27M mutant–negative HGSG counterparts. Further preclinical animal studies and larger clinical studies are needed to further understand the age-dependent effects of H3 K27M mutation.

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Xuguang Chen, Sheng-Fu L. Lo, Chetan Bettegowda, Daniel M. Ryan II, John M. Gross, Chen Hu, Lawrence Kleinberg, Daniel M. Sciubba, and Kristin J. Redmond

OBJECTIVE

Spinal chordoma is locally aggressive and has a high rate of recurrence, even after en bloc resection. Conventionally fractionated adjuvant radiation leads to suboptimal tumor control, and data regarding hypofractionated regimens are limited. The authors hypothesized that neoadjuvant stereotactic body radiotherapy (SBRT) may overcome its intrinsic radioresistance, improve surgical margins, and allow preservation of critical structures during surgery. The purpose of this study is to review the feasibility and early outcomes of high-dose hypofractionated SBRT, with a focus on neoadjuvant SBRT.

METHODS

Electronic medical records of patients with spinal chordoma treated using image-guided SBRT between 2009 and 2019 at a single institution were retrospectively reviewed.

RESULTS

Twenty-eight patients with 30 discrete lesions (24 in the mobile spine) were included. The median follow-up duration was 20.8 months (range 2.3–126.3 months). The median SBRT dose was 40 Gy (range 15–50 Gy) in 5 fractions (range 1–5 fractions). Seventeen patients (74% of those with newly diagnosed lesions) received neoadjuvant SBRT, of whom 15 (88%) underwent planned en bloc resection, all with negative margins. Two patients (12%) developed surgical wound-related complications after neoadjuvant SBRT and surgery, and 4 (two grade 3 and two grade 2) experienced postoperative complications unrelated to the surgical site. Of the remaining patients with newly diagnosed lesions, 5 received adjuvant SBRT for positive or close surgical margins, and 1 received SBRT alone. Seven recurrent lesions were treated with SBRT alone, including 2 after failure of prior conventional radiation. The 2-year overall survival rate was 92% (95% confidence interval [CI] 71%–98%). Patients with newly diagnosed chordoma had longer median survival (not reached) than those with recurrent lesions (27.7 months, p = 0.006). The 2-year local control rate was 96% (95% CI 74%–99%). Among patients with radiotherapy-naïve lesions, no local recurrence was observed with a biologically effective dose ≥ 140 Gy, maximum dose of the planning target volume (PTV) ≥ 47 Gy, mean dose of the PTV ≥ 39 Gy, or minimum dose to 80% of the PTV ≥ 36 Gy (5-fraction equivalent doses). All acute toxicities from SBRT were grade 1–2, and no myelopathy was observed.

CONCLUSIONS

Neoadjuvant high-dose, hypofractionated SBRT for spinal chordoma is safe and does not increase surgical morbidities. Early outcomes at 2 years are promising, although long-term follow-up is pending.

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Zach Pennington, Jeff Ehresman, Andrew Schilling, James Feghali, Andrew M. Hersh, Bethany Hung, Eleni N. Kalivas, Daniel Lubelski, and Daniel M. Sciubba

OBJECTIVE

Patients with spine tumors are at increased risk for both hemorrhage and venous thromboembolism (VTE). Tranexamic acid (TXA) has been advanced as a potential intervention to reduce intraoperative blood loss in this surgical population, but many fear it is associated with increased VTE risk due to the hypercoagulability noted in malignancy. In this study, the authors aimed to 1) develop a clinical calculator for postoperative VTE risk in the population with spine tumors, and 2) investigate the association of intraoperative TXA use and postoperative VTE.

METHODS

A retrospective data set from a comprehensive cancer center was reviewed for adult patients treated for vertebral column tumors. Data were collected on surgery performed, patient demographics and medical comorbidities, VTE prophylaxis measures, and TXA use. TXA use was classified as high-dose (≥ 20 mg/kg) or low-dose (< 20 mg/kg). The primary study outcome was VTE occurrence prior to discharge. Secondary outcomes were deep venous thrombosis (DVT) or pulmonary embolism (PE). Multivariable logistic regression was used to identify independent risk factors for VTE and the resultant model was deployed as a web-based calculator.

RESULTS

Three hundred fifty patients were included. The mean patient age was 57 years, 53% of patients were male, and 67% of surgeries were performed for spinal metastases. TXA use was not associated with increased VTE (14.3% vs 10.1%, p = 0.37). After multivariable analysis, VTE was independently predicted by lower serum albumin (odds ratio [OR] 0.42 per g/dl, 95% confidence interval [CI] 0.23–0.79, p = 0.007), larger mean corpuscular volume (OR 0.91 per fl, 95% CI 0.84–0.99, p = 0.035), and history of prior VTE (OR 2.60, 95% CI 1.53–4.40, p < 0.001). Longer surgery duration approached significance and was included in the final model. Although TXA was not independently associated with the primary outcome of VTE, high-dose TXA use was associated with increased odds of both DVT and PE. The VTE model showed a fair fit of the data with an area under the curve of 0.77.

CONCLUSIONS

In the present cohort of patients treated for vertebral column tumors, TXA was not associated with increased VTE risk, although high-dose TXA (≥ 20 mg/kg) was associated with increased odds of DVT or PE. Additionally, the web-based clinical calculator of VTE risk presented here may prove useful in counseling patients preoperatively about their individualized VTE risk.

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Wuyang Yang, Jordina Rincon-Torroella, James Feghali, Adham M. Khalafallah, Wataru Ishida, Alexander Perdomo-Pantoja, Alfredo Quiñones-Hinojosa, Michael Lim, Gary L. Gallia, Gregory J. Riggins, William S. Anderson, Sheng-Fu Larry Lo, Daniele Rigamonti, Rafael J. Tamargo, Timothy F. Witham, Ali Bydon, Alan R. Cohen, George I. Jallo, Alban Latremoliere, Mark G. Luciano, Debraj Mukherjee, Alessandro Olivi, Lintao Qu, Ziya L. Gokaslan, Daniel M. Sciubba, Betty Tyler, Henry Brem, and Judy Huang

OBJECTIVE

International research fellows have been historically involved in academic neurosurgery in the United States (US). To date, the contribution of international research fellows has been underreported. Herein, the authors aimed to quantify the academic output of international research fellows in the Department of Neurosurgery at The Johns Hopkins University School of Medicine.

METHODS

Research fellows with Doctor of Medicine (MD), Doctor of Philosophy (PhD), or MD/PhD degrees from a non-US institution who worked in the Hopkins Department of Neurosurgery for at least 6 months over the past decade (2010–2020) were included in this study. Publications produced during fellowship, number of citations, and journal impact factors (IFs) were analyzed using ANOVA. A survey was sent to collect information on personal background, demographics, and academic activities.

RESULTS

Sixty-four international research fellows were included, with 42 (65.6%) having MD degrees, 17 (26.6%) having PhD degrees, and 5 (7.8%) having MD/PhD degrees. During an average 27.9 months of fellowship, 460 publications were produced in 136 unique journals, with 8628 citations and a cumulative journal IF of 1665.73. There was no significant difference in total number of publications, first-author publications, and total citations per person among the different degree holders. Persons holding MD/PhDs had a higher number of citations per publication per person (p = 0.027), whereas those with MDs had higher total IFs per person (p = 0.048). Among the 43 (67.2%) survey responders, 34 (79.1%) had nonimmigrant visas at the start of the fellowship, 16 (37.2%) were self-paid or funded by their country of origin, and 35 (81.4%) had mentored at least one US medical student, nonmedical graduate student, or undergraduate student.

CONCLUSIONS

International research fellows at the authors’ institution have contributed significantly to academic neurosurgery. Although they have faced major challenges like maintaining nonimmigrant visas, negotiating cultural/language differences, and managing self-sustainability, their scientific productivity has been substantial. Additionally, the majority of fellows have provided reciprocal mentorship to US students.

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Andrew Hersh, Robert Young, Zach Pennington, Jeff Ehresman, Andy Ding, Srujan Kopparapu, Ethan Cottrill, Daniel M. Sciubba, and Nicholas Theodore

OBJECTIVE

Currently, no consensus exists as to whether patients who develop infection of the surgical site after undergoing instrumented fusion should have their implants removed at the time of wound debridement. Instrumentation removal may eliminate a potential infection nidus, but removal may also destabilize the patient’s spine. The authors sought to summarize the existing evidence by systematically reviewing published studies that compare outcomes between patients undergoing wound washout and instrumentation removal with outcomes of patients undergoing wound washout alone. The primary objectives were to determine 1) whether instrumentation removal from an infected wound facilitates infection clearance and lowers morbidity, and 2) whether the chronicity of the underlying infection affects the decision to remove instrumentation.

METHODS

PRISMA guidelines were used to review the PubMed/MEDLINE, Embase, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify studies that compared patients with implants removed and patients with implants retained. Outcomes of interest included mortality, rate of repeat wound washout, and loss of correction.

RESULTS

Fifteen articles were included. Of 878 patients examined in these studies, 292 (33%) had instrumentation removed. Patient populations were highly heterogeneous, and outcome data were limited. Available data suggested that rates of reoperation, pseudarthrosis, and death were higher in patients who underwent instrumentation removal at the time of initial washout. Three studies recommended that instrumentation be uniformly removed at the time of wound washout. Five studies favored retaining the original instrumentation. Six studies favored retention in early infections but removal in late infections.

CONCLUSIONS

The data on this topic remain heterogeneous and low in quality. Retention may be preferred in the setting of early infection, when the risk of underlying spine instability is still high and the risk of mature biofilm formation on the implants is low. However, late infections likely favor instrumentation removal. Higher-quality evidence from large, multicenter, prospective studies is needed to reach generalizable conclusions capable of guiding clinical practice.

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Adham M. Khalafallah, Adrian E. Jimenez, Nathan A. Shlobin, Collin J. Larkin, Debraj Mukherjee, Corinna C. Zygourakis, Sheng-Fu Lo, Daniel M. Sciubba, Ali Bydon, Timothy F. Witham, Nader S. Dahdaleh, and Nicholas Theodore

OBJECTIVE

Although fellowship training is becoming increasingly common in neurosurgery, it is unclear which factors predict an academic career trajectory among spinal neurosurgeons. In this study, the authors sought to identify predictors associated with academic career placement among fellowship-trained neurological spinal surgeons.

METHODS

Demographic data and bibliometric information on neurosurgeons who completed a residency program accredited by the Accreditation Council for Graduate Medical Education between 1983 and 2019 were gathered, and those who completed a spine fellowship were identified. Employment was denoted as academic if the hospital where a neurosurgeon worked was affiliated with a neurosurgical residency program; all other positions were denoted as nonacademic. A logistic regression model was used for multivariate statistical analysis.

RESULTS

A total of 376 fellowship-trained spinal neurosurgeons were identified, of whom 140 (37.2%) held academic positions. The top 5 programs that graduated the most fellows in the cohort were Cleveland Clinic, The Johns Hopkins Hospital, University of Miami, Barrow Neurological Institute, and Northwestern University. On multivariate analysis, increased protected research time during residency (OR 1.03, p = 0.044), a higher h-index during residency (OR 1.12, p < 0.001), completing more than one clinical fellowship (OR 2.16, p = 0.024), and attending any of the top 5 programs that graduated the most fellows (OR 2.01, p = 0.0069) were independently associated with an academic career trajectory.

CONCLUSIONS

Increased protected research time during residency, a higher h-index during residency, completing more than one clinical fellowship, and attending one of the 5 programs graduating the most fellowship-trained neurosurgical spinal surgeons independently predicted an academic career. These results may be useful in identifying and advising trainees interested in academic spine neurosurgery.

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Adham M. Khalafallah, Adrian E. Jimenez, Nathan A. Shlobin, Collin J. Larkin, Debraj Mukherjee, Corinna C. Zygourakis, Sheng-Fu Lo, Daniel M. Sciubba, Ali Bydon, Timothy F. Witham, Nader S. Dahdaleh, and Nicholas Theodore

OBJECTIVE

Although fellowship training is becoming increasingly common in neurosurgery, it is unclear which factors predict an academic career trajectory among spinal neurosurgeons. In this study, the authors sought to identify predictors associated with academic career placement among fellowship-trained neurological spinal surgeons.

METHODS

Demographic data and bibliometric information on neurosurgeons who completed a residency program accredited by the Accreditation Council for Graduate Medical Education between 1983 and 2019 were gathered, and those who completed a spine fellowship were identified. Employment was denoted as academic if the hospital where a neurosurgeon worked was affiliated with a neurosurgical residency program; all other positions were denoted as nonacademic. A logistic regression model was used for multivariate statistical analysis.

RESULTS

A total of 376 fellowship-trained spinal neurosurgeons were identified, of whom 140 (37.2%) held academic positions. The top 5 programs that graduated the most fellows in the cohort were Cleveland Clinic, The Johns Hopkins Hospital, University of Miami, Barrow Neurological Institute, and Northwestern University. On multivariate analysis, increased protected research time during residency (OR 1.03, p = 0.044), a higher h-index during residency (OR 1.12, p < 0.001), completing more than one clinical fellowship (OR 2.16, p = 0.024), and attending any of the top 5 programs that graduated the most fellows (OR 2.01, p = 0.0069) were independently associated with an academic career trajectory.

CONCLUSIONS

Increased protected research time during residency, a higher h-index during residency, completing more than one clinical fellowship, and attending one of the 5 programs graduating the most fellowship-trained neurosurgical spinal surgeons independently predicted an academic career. These results may be useful in identifying and advising trainees interested in academic spine neurosurgery.