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Ali A. Baaj, Juan S. Uribe and Fernando L. Vale

Chance-type fractures of the spine have been associated with seat-belt injuries in the pediatric population. Nonoperative management is appropriate in most cases of Chance fractures, but surgical intervention is occasionally warranted to deter progression of kyphosis and neurological deterioration. Internal fixation using pedicle screws has been widely used in the surgical repair of this injury. The authors report on a 6-year-old girl who suffered an L-2 Chance fracture with facet disruption, kyphosis, and significant posterior ligamentous injury. She underwent open reduction and internal fixation using Songer cable wiring augmented with bilateral lamina plating. At the 18-week follow-up, she continued to be free of any neurological deficits and her alignment was stable on plain radiographs of flexion-extension. The authors have therefore described a feasible option in the surgical management of Chance-type fractures in the pediatric spine.

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Ali A. Baaj, Siviero Agazzi and Harry van Loveren

Cerebral revascularization constitutes an important treatment modality in the management of complex aneurysms, carotid occlusion, tumor, and moyamoya disease. Graft selection is a critical step in the planning of revascularization surgery, and depends on an understanding of graft and regional hemodynamics, accessibility, and patency rates. The goal of this review is to highlight some of these properties.

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Andrew C. Vivas, Ali A. Baaj, Selim R. Benbadis and Fernando L. Vale

Object

The aim of this study was to analyze the national health care burden of patients diagnosed with epilepsy in the US and to analyze any changes in the length of stay, mean charges, in-hospital deaths (mortality), and disposition at discharge.

Methods

A retrospective review of the Nationwide Inpatient Sample (NIS) database for epilepsy admissions was completed for the years from 1993 to 2008. The NIS is maintained by the Agency for Healthcare Research and Quality and represents a 20% random stratified sample of all discharges from nonfederal hospitals within the US. Patients with epilepsy were identified using ICD-9 codes beginning with 345.XX. Approximately 1.1 million hospital admissions were identified over a span of 15 years.

Results

Over this 15-year period (between 1993 and 2008), the average hospital charge per admission for patients with epilepsy has increased significantly (p < 0.001) from $10,050 to $23,909, an increase of 137.9%. This is in spite of a 33% decrease in average length of stay from 5.9 days to 3.9 days. There has been a decrease in the percentage of in-hospital deaths by 57.9% and an increase in discharge to outside medical institutions.

Conclusions

The total national charges associated with epilepsy in 2008 were in excess of $2.7 billion (US dollars, normalized). During the studied period, the cost per day for patients rose from $1703.39 to $6130.51. In spite of this drastic increase in health care cost to the patient, medical and surgical treatment for epilepsy has not changed significantly, and epilepsy remains a major source of morbidity.

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Ali A. Baaj, Douglas Brockmeyer, Andrew Jea and Amer F. Samdani

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Vernard S. Fennell, Sheri Palejwala, Jesse Skoch, David A. Stidd and Ali A. Baaj

Object

Experience with freehand thoracic pedicle screw placement is well described in the literature. Published techniques rely on various starting points and trajectories for each level or segment of the thoracic spine. Furthermore, few studies provide specific guidance on sagittal and axial trajectories. The goal of this study was to propose a uniform entry point and sagittal trajectory for all thoracic levels during freehand pedicle screw placement and determine the accuracy of this technique.

Methods

The authors retrospectively reviewed postoperative CT scans of 33 consecutive patients who underwent open, freehand thoracic pedicle-screw fixation using a uniform entry point and sagittal trajectory for all levels. The same entry point for each level was defined as a point 3 mm caudal to the junction of the transverse process and the lateral margin of the superior articulating process, and the sagittal trajectory was always orthogonal to the dorsal curvature of the spine at that level. The medial angulation (axial trajectory) was approximately 30° at T-1 and T-2, and 20° from T-3 to T-12. Breach was defined as greater than 25% of the screw diameter residing outside of the pedicle or vertebral body.

Results

A total of 219 thoracic pedicle screws were placed with a 96% accuracy rate. There were no medial breaches and 9 minor lateral breaches (4.1%). None of the screws had to be repositioned postoperatively, and there were no neurovascular complications associated with the breaches.

Conclusions

It is feasible to place freehand thoracic pedicle screws using a uniform entry point and sagittal trajectory for all levels. The entry point does not have to be adjusted for each level as reported in existing studies, although this technique was not tested in severe scoliotic spines. While other techniques are effective and widely used, this particular method provides more specific parameters and may be easier to learn, teach, and adopt.

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Ali A. Baaj, Selim R. Benbadis, William O. Tatum and Fernando L. Vale

Object

Vagus nerve stimulation (VNS) plays a significant role in the treatment of intractable epilepsy. The goal of this study was to analyze trends in the use of VNS for epilepsy in the US by using a nationwide database.

Methods

Data for patients undergoing VNS were obtained from the nationwide inpatient sample for the years 1998–2005. Trends regarding number of procedures, length of stay (LOS), hospital charges, patient sex, and payer information were retrieved and analyzed.

Results

The number of VNS procedures for epilepsy increased between 1998 and 2003 but decreased in the subsequent 2 years. The LOS and hospital charges showed yearly increases. Female patients underwent VNS implantation more than males did, and most procedures were performed in the 18- to 64-year-old age group. The combination of Medicare and Medicaid provided most of the funding for VNS from 2002 through 2005. The VNS procedures were performed mostly in teaching hospitals.

Conclusions

Trends from a national database reveal consistent use of VNS for intractable epilepsy. Greater use of the procedure appears to be reflected in the female population, and the procedure has been performed most often at tertiary care teaching hospitals, where a comprehensive evaluation for all forms of therapy is arguably best able to target appropriate patients for appropriate therapies. With the recent application of VNS to target populations without epilepsy, such as patients with refractory depression, the trend of continued use of this treatment for epilepsy appears likely.

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Ali A. Baaj and Ziya L. Gokaslan

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Juan S. Uribe, Edwin Ramos, Sammy Youssef, Fernando L. Vale and Ali A. Baaj

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Dzenan Lulic, Amir Ahmadian, Ali A. Baaj, Selim R. Benbadis and Fernando L. Vale

Vagus nerve stimulation (VNS) is a key tool in the treatment of patients with medically refractory epilepsy. Although the mechanism of action of VNS remains poorly understood, this modality is now the most widely used nonpharmacological treatment for drug-resistant epilepsy. The goal of this work is to review the history of VNS and provide information on recent advances and applications of this technology.

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Ali A. Baaj, Katheryne Downes, Alexander R. Vaccaro, Juan S. Uribe and Fernando L. Vale

Object

The objective of this study was to investigate a national health care database and analyze demographics, hospital charges, and treatment trends of patients diagnosed with lumbar spine fractures in the US over a 5-year period.

Methods

Clinical data were derived from the Nationwide Inpatient Sample (NIS) for the years 2003 through 2007. The NIS is maintained by the Agency for Healthcare Research and Quality and represents a 20% random stratified sample of all discharges from nonfederal hospitals within the US. Patients with lumbar spine fractures were identified using the appropriate ICD-9-CM code. Data on the number of vertebral body augmentation procedures were also retrieved. National estimates of discharges, hospital charges, discharge patterns, and treatment with spinal fusion trends were retrieved and analyzed.

Results

More than 190,000 records of patients with lumbar spine fractures were abstracted from the database. During the 5-year period, there was a 17% increase in hospitalizations for lumbar spine fractures. This was associated with a 27% increase in hospital charges and a 55% increase in total national charges (both adjusted for inflation). The total health care bill associated with lumbar spine fractures in 2007 exceeded 1 billion US dollars. During this same time period, there was a 24% increase in spinal fusions for lumbar fractures, which was associated with a 15% increase in hospital charges. The ratio of spinal fusions to hospitalizations (surgical rate) during this period, however, was stable with an average of 7.4% over the 5-year period. There were an estimated 13,000 vertebral body augmentation procedures for nonpathological fractures performed in 2007 with a total national bill of 450 million US dollars.

Conclusions

An increasing trend of hospitalizations, surgical treatment, and charges associated with lumbar spine fractures was observed between 2003 and 2007 on a national level. This trend, however, does not appear to be as steep as that of surgical utilization in degenerative spine disease. Furthermore, the ratio of spinal fusions to hospitalizations for lumbar fractures appears to be stable, possibly indicating no significant changes in indications for surgical intervention over the time period studied.