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Rachid Assina, Christina E. Sarris, and Antonios Mammis

Both the history of headache and the practice of craniotomy can be traced to antiquity. From ancient times through the present day, numerous civilizations and scholars have performed craniotomy in attempts to treat headache. Today, surgical intervention for headache management is becoming increasingly more common due to improved technology and greater understanding of headache. By tracing the evolution of the understanding of headache alongside the practice of craniotomy, investigators can better evaluate the mechanisms of headache and the therapeutic treatments used today.

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Christina E. Sarris, Griffin D. Santarelli, and Andrew S. Little

This video demonstrates the transorbital approach for endoscopic repair of an anterior skull base encephalocele. The patient is a 77-year-old man with morbid obesity and a 2-year history of left-sided cerebrospinal fluid (CSF) rhinorrhea and radiographic evidence of an anterior skull base defect with an encephalocele. An endoscopic transorbital approach was chosen for repair because of its minimally invasive access to the anterolateral skull base. The patient had an excellent clinical outcome with resolution of the CSF rhinorrhea and preservation of full vision and extraocular muscle function.

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Christina E. Sarris, Krystal L. Tomei, Peter W. Carmel, and Chirag D. Gandhi

Lipomyelomeningocele represents a rare but complex neurological disorder that may present with neurological deterioration secondary to an inherent tethered spinal cord. Radiological testing is beneficial in determining the morphology of the malformation. Specialized testing such as urodynamic studies and neurophysiological testing may be beneficial in assessing for neurological dysfunction secondary to the lipomyelomeningocele. Early surgical intervention may be beneficial in preventing further neurological decline.

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Rachid Assina, Sebastian Rubino, Christina E. Sarris, Chirag D. Gandhi, and Charles J. Prestigiacomo

Early neurosurgical procedures dealt mainly with treatment of head trauma, especially skull fractures. Since the early medical writings by Hippocrates, a great deal of respect was given to the dura mater, and many other surgeons warned against violating the dura. It was not until the 19th century that neurosurgeons started venturing beneath the dura, deep into the brain parenchyma. With this advancement, brain retraction became an essential component of intracranial surgery. Over the years brain retractors have been created pragmatically to provide better visualization, increased articulations and degrees of freedom, greater stability, less brain retraction injury, and less user effort. Brain retractors have evolved from simple handheld retractors to intricate brain-retraction systems with hand-rest stabilizers. This paper will focus on the history of brain retractors, the different types of retractors, and the progression from one form to another.

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Christina E. Sarris, Scott T. Brigeman, Estelle Doris, Maggie Bobrowitz, Thomas Rowe, Eva M. Duran, Griffin D. Santarelli, Ryan M. Rehl, Garineh Ovanessoff, Monica C. Rodriguez, Kajalben Buddhdev, Kevin C. J. Yuen, and Andrew S. Little


A comprehensive quality improvement (QI) program aimed at all aspects of patient care after pituitary surgery was initiated at a single center. This initiative was guided by standard quality principles to improve patient outcomes and optimize healthcare value. The programmatic goal was to discharge most elective patients within 1 day after surgery, improve patient safety, and limit unplanned readmissions. The program is described, and its effect on patient outcomes and hospital financial performance over a 5-year period are investigated.


Details of the patient care pathway are presented. Foundational elements of the QI program include evidence-based care pathways (e.g., for hyponatremia and pain), an in-house research program designed to fortify care pathways, patient education, expectation setting, multidisciplinary team care, standard order sets, high-touch postdischarge care, outcomes auditing, and a patient navigator, among other elements. Length of stay (LOS), outcome variability, 30-day unplanned readmissions, and hospital financial performance were identified as surrogate endpoints for healthcare value for the surgical epoch. To assess the effect of these protocols, all patients undergoing elective transsphenoidal surgery for pituitary tumors and Rathke’s cleft cysts between January 2015 and December 2019 were reviewed.


A total of 609 adult patients who underwent elective surgery by experienced pituitary surgeons were identified. Patient demographics, comorbidities, and payer mix did not change significantly over the study period (p ≥ 0.10). The mean LOS was significantly shorter in 2019 versus 2015 (1.6 ± 1.0 vs 2.9 ± 2.2 midnights, p < 0.001). The percentage of patients discharged after 1 midnight was significantly higher in 2019 versus 2015 (75.4% vs 15.6%, p < 0.001). The 30-day unplanned hospital readmission rate decreased to 2.8% in 2019 from 8.3% in 2015. Per-patient hospital profit increased 71.3% ($10,613 ± $19,321 in 2015; $18,180 ± $21,930 in 2019), and the contribution margin increased 42.3% ($18,925 ± $19,236 in 2015; $26,939 ± $22,057 in 2019), while costs increased by only 3.4% ($18,829 ± $6611 in 2015; $19,469 ± $4291 in 2019).


After implementation of a comprehensive pituitary surgery QI program, patient outcomes significantly improved, outcome variability decreased, and hospital financial performance was enhanced. Future studies designed to evaluate disease remission, patient satisfaction, and how the surgeon learning curve may synergize with other quality efforts may provide additional context.