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Christian B. Kaufman, Jonathan W. Mink, and Jason M. Schwalb

The authors present the case of a 26-year-old man with a 10–15-year history of worsening bilateral dystonia and baseline chorea occurring up to 20 times per day that was exacerbated by stress and anxiety and was refractory to medical management. Paroxysmal nonkinesigenic dyskinesia was diagnosed, which is a rare, hyperkinetic movement disorder that is episodic and does not respond to nonbenzodiazepine antiepileptics. The patient was significantly debilitated by his disease, lived in a group home, and suffered from frequent falls, necessitating the wearing of a protective helmet and face mask at all times.

The patient underwent implantation of bilateral deep brain stimulation quadripolar electrodes in the globus pallidus internus with the aid of image-guided stereotactic neurosurgery and microelectrode recording without complication.

At his 1-month postoperative follow-up, the patient reported a subjective 90% improvement in his symptoms; the only notable side effect was a slight increased slurring in his baseline dysarthria. Objective reporting and recording forms maintained by the patient's caretakers over the following 18 months suggested a significant and sustained improvement in his overall balance, ambulation, and gross motor function with a substantial decrease in the incidence of reported falls.

The authors conclude that pallidal deep brain stimulation may be successfully applied to patients suffering from refractory paroxysmal nonkinesigenic dyskinesia with promising results. This treatment strategy deserves further prospective investigation, clinical consideration, and refinement.

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Rushna Ali, Jason M. Schwalb, David R. Nerenz, Heath J. Antoine, and Ilan Rubinfeld

OBJECTIVE

Limited tools exist to stratify perioperative risk in patients undergoing spinal procedures. The modified frailty index (mFI) based on the Canadian Study of Health and Aging Frailty Index (CSHA-FI), constructed from standard demographic variables, has been applied to various other surgical populations for risk stratification. The authors hypothesized that it would be predictive of postoperative morbidity and mortality in patients undergoing spine surgery.

METHODS

The 2006–2010 National Surgical Quality Improvement Program (NSQIP) data set was accessed for patients undergoing spine surgeries based on Current Procedural Terminology (CPT) codes. Sixteen preoperative clinical NSQIP variables were matched to 11 CSHA-FI variables (changes in daily activities, gastrointestinal problems, respiratory problems, clouding or delirium, hypertension, coronary artery and peripheral vascular disease, congestive heart failure, and so on). The outcomes assessed were 30-day occurrences of adverse events. These were then summarized in groups: any infection, wound-related complication, Clavien IV complications (life-threatening, requiring ICU admission), and mortality.

RESULTS

A total of 18,294 patients were identified. In 8.1% of patients with an mFI of 0 there was at least one morbid complication, compared with 24.3% of patients with an mFI of ≥ 0.27 (p < 0.001). An mFI of 0 was associated with a mortality rate of 0.1%, compared with 2.3% for an mFI of ≥ 0.27 (p < 0.001). Patients with an mFI of 0 had a 1.7% rate of surgical site infections and a 0.8% rate of Clavien IV complications, whereas patients with an mFI of ≥ 0.27 had rates of 4.1% and 7.1% for surgical site infections and Clavien IV complications, respectively (p < 0.001 for both). Multivariate analysis showed that the preoperative mFI and American Society of Anesthesiologists classification of ≥ III had a significantly increased risk of leading to Clavien IV complications and death.

CONCLUSIONS

A higher mFI was associated with a higher risk of postoperative morbidity and mortality, providing an additional tool to improve perioperative risk stratification.

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Jason M. Schwalb, Kim J. Burchiel, Parag G. Patil, and Tipu Z. Aziz

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Jason M. Schwalb, Howard A. Riina, Brett Skolnick, Jurg L. Jaggi, Tanya Simuni, and Gordon H. Baltuch

✓ The treatment of essential tremor with thalamic deep brain stimulation (DBS) is considered to be more effective and to cause less morbidity than treatment with thalamotomy. Nonetheless, implantation of an indwelling electrode, connectors, and a generator is associated with specific types of morbidity. The authors describe three patients who required revision of their DBS systems due to lead breakage. The connector between the DBS electrode and the extension wire, which connects to the subclavicular pulse generator, was originally placed subcutaneously in the cervical region to decrease the risk of erosion through the scalp and to improve cosmesis. Three patients presented with fractured DBS electrodes that were located in the cervical region near the connector, necessitating reoperation with stereotactic retargeting and placement of a new intracranial electrode. At reoperation, the connectors were placed subgaleally over the parietal region.

Management of these cases has led to modifications in the operative procedure designed to improve the durability of DBS systems. The authors recommend that surgeons avoid placing the connection between the DBS electrode and the extension wire in the cervical region because patient movement can cause microfractures in the electrode. Such microfractures require intracranial revision, which may be associated with a higher risk of morbidity than the initial operation. The authors also recommend considering prophylactic relocation of the connectors from the cervical area to the subgaleal parietal region to decrease the risk of future DBS electrode fracture, which would necessitate a more lengthy procedure to revise the intracranial electrode.

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Hesham Mostafa Zakaria, Tarek R. Mansour, Edvin Telemi, Karam Asmaro, Mohamed Macki, Michael Bazydlo, Lonni Schultz, David R. Nerenz, Muwaffak Abdulhak, Jason M. Schwalb, Paul Park, and Victor Chang

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality-improvement collaborative. Using MSSIC, the authors sought to identify the relationship between a positive Patient Health Questionnaire–2 (PHQ-2) screening, which is predictive of depression, and patient satisfaction, return to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion.

METHODS

Data from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage.

RESULTS

Multivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion.

CONCLUSIONS

A multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

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Hesham Mostafa Zakaria, Michael Bazydlo, Lonni Schultz, Markian A. Pahuta, Jason M. Schwalb, Paul Park, Ilyas Aleem, David R. Nerenz, Victor Chang, and for the MSSIC Investigators

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.

METHODS

A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.

RESULTS

Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.

CONCLUSIONS

A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

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Victor Chang, Jason M. Schwalb, David R. Nerenz, Lisa Pietrantoni, Sharon Jones, Michelle Jankowski, Nancy Oja-Tebbe, Stephen Bartol, and Muwaffak Abdulhak

OBJECT

Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved—and continue to improve—the quality of patient care throughout the state of Michigan.

METHODS

MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals.

RESULTS

As of July 1, 2015, a total of 6397 cases have been entered into the registry. This number reflects 4824 eligible cases with confirmed surgery dates. Of these 4824 eligible cases, 3338 cases went beyond the 120-day window and were considered eligible for the extraction of surgical details, 90-day outcomes, and adverse events. Among these 3338 patients, there are a total of 2469 lumbar cases, 862 cervical cases, and 7 combined procedures that were entered into the registry.

CONCLUSIONS

In addition to functioning as a registry, MSSIC is also meant to be a platform for quality improvement with the potential for future initiatives and best practices to be implemented statewide in order to improve quality and lower costs. With its current rate of recruitment and expansion, MSSIC will provide a robust platform as a regional prospective registry. Its unique funding model, which is supported by BCBSM/BCN, will help ensure its longevity and viability, as has been observed in other CQIs that have been active for several years.

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Kevin Reinard, David R. Nerenz, Azam Basheer, Rizwan Tahir, Timothy Jelsema, Lonni Schultz, Ghaus Malik, Ellen L. Air, and Jason M. Schwalb

OBJECTIVE

A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. The authors sought to identify racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN), as well as the potential underlying reasons for those disparities, which could serve as areas of focus for future quality improvement initiatives.

METHODS

The medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, at the Henry Ford Medical Group (HFMG) in the period from 2006 to 2012 were searched, and clinical and socioeconomic data were retrospectively reviewed. Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken for patients with TN.

RESULTS

The authors identified 652 patients eligible for analysis. Compared with white patients, black patients were less likely to undergo percutaneous ablative procedures, stereotactic radiosurgery, or microvascular decompression (p < 0.001). However, there was no difference in the likelihood of blacks and whites undergoing a procedure once they had seen a neurosurgeon (67% vs 70%, respectively; p = 0.712). Blacks and whites were equally likely to be seen by a neurologist or neurosurgeon if they were initially seen in either the emergency room (38% vs 37%, p = 0.879) or internal medicine (48% vs 50%, p = 0.806). Among patients diagnosed (268 patients) after the 2008 publication of the European Federation of Neurological Societies and the American Academy of Neurology guidelines for medical therapy for TN, fewer than 50% were on medications sanctioned by the guidelines, and there were no statistically significant racial disparities between white and black patients (p = 0.060).

CONCLUSIONS

According to data from a large database from one of the nation's largest comprehensive health care systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for TN. This appeared to stem from outside HFMG from a difference in referral patterns to the neurologists and neurosurgeons.

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Paul Park, Victor Chang, Hsueh-Han Yeh, Jason M. Schwalb, David R. Nerenz, Lonni R. Schultz, Muwaffak M. Abdulhak, Richard Easton, Miguelangelo Perez-Cruet, Osama N. Kashlan, Mark E. Oppenlander, Nicholas J. Szerlip, Kevin N. Swong, and Ilyas S. Aleem

OBJECTIVE

In 2017, Michigan passed new legislation designed to reduce opioid abuse. This study evaluated the impact of these new restrictive laws on preoperative narcotic use, short-term outcomes, and readmission rates after spinal surgery.

METHODS

Patient data from 1 year before and 1 year after initiation of the new opioid laws (beginning July 1, 2018) were queried from the Michigan Spine Surgery Improvement Collaborative database. Before and after implementation of the major elements of the new laws, 12,325 and 11,988 patients, respectively, were treated.

RESULTS

Patients before and after passage of the opioid laws had generally similar demographic and surgical characteristics. Notably, after passage of the opioid laws, the number of patients taking daily narcotics preoperatively decreased from 3783 (48.7%) to 2698 (39.7%; p < 0.0001). Three months postoperatively, there were no differences in minimum clinically important difference (56.0% vs 58.0%, p = 0.1068), numeric rating scale (NRS) score of back pain (3.5 vs 3.4, p = 0.1156), NRS score of leg pain (2.7 vs 2.7, p = 0.3595), satisfaction (84.4% vs 84.7%, p = 0.6852), or 90-day readmission rate (5.8% vs 6.2%, p = 0.3202) between groups. Although there was no difference in readmission rates, pain as a reason for readmission was marginally more common (0.86% vs 1.22%, p = 0.0323).

CONCLUSIONS

There was a meaningful decrease in preoperative narcotic use, but notably there was no apparent negative impact on postoperative recovery, patient satisfaction, or short-term outcomes after spinal surgery despite more restrictive opioid prescribing. Although the readmission rate did not significantly increase, pain as a reason for readmission was marginally more frequently observed.