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Matthew J. Pierson, Daniel Wehrmann, J. Andrew Albers, Najib E. El Tecle, Dary Costa and Samer K. Elbabaa

OBJECTIVE

Patients with ventriculoperitoneal (VP) shunts with programmable valves who would benefit from osseointegrated hearing devices (OIHDs) represent a unique population. The aim of this study was to evaluate the magnetic field strengths of 4 OIHDs and their interactions with 5 programmable VP shunt valves.

METHODS

Magnetic field strength was measured as a function of distance for each hearing device (Cochlear Baha 5, Cochlear Baha BP110, Oticon Ponto Plus Power, and Medtronic Sophono) in the following modes: inactive, active in quiet, and active in 60 decibels of background noise in the sound booth. The hearing devices were introduced to each shunt valve (Aesculap proGAV, Aesculap proGAV 2.0, Codman Hakim, Codman Certas, and Medtronic Strata II) also as a function of distance in these identical 3 settings. Each trial was repeated 5 times. Between each trial, the valves were assessed for a change in setting. Finally, using a skull model, the devices were introduced to each other in standard anatomical locations and the valves were assessed for a change in settings.

RESULTS

The maximum magnetic field strengths generated by the Cochlear Baha 5, BP110, and Oticon OIHDs were 1.1, 36.2, and 48.7 gauss (G), respectively. The maximum strength generated by the Sophono device was > 800 G. The magnetic field strength of the hearing devices decreased markedly with increasing distance from the device. The strength of the Sophono's magnetic attachment decreased to 34.8 G at 5 mm. The Codman Hakim, Codman Certas, and Medtronic Strata II valve settings changed when rotating the valves next to the Sophono abutment. No other changes in valve settings occurred in the distance or anatomical models for any other trials.

CONCLUSIONS

This is the first study evaluating the interaction between OIHDs and programmable VP shunt valves. The findings suggest that it is safe to use these devices together without having to switch to a nonprogrammable valve or move the shunt valve to a more distant location. Still, care should be taken if the Sophono device is used to ensure that the valve is ≥ 5 mm away from the magnetic attachment.

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Najib E. El Tecle, Nader S. Dahdaleh, Mohamad Bydon, Wilson Z. Ray, James C. Torner and Patrick W. Hitchon

OBJECTIVE

The natural history of complete spinal cord injury (SCI) is poorly studied. The classically quoted rate of improvement or conversion for patients with American Spinal Injury Association (ASIA) grade A (ASIA A) injuries is 15%–20%; however, data supporting this rate are very limited. In this paper, the authors conducted a meta-analysis of modern data reporting on ASIA A patients and evaluated factors affecting the natural history of the disease.

METHODS

The authors conducted a systematic literature review of all randomized clinical trials (RCTs) and observational studies of patients with traumatic SCI. The Embase, MEDLINE, PubMed, Scopus, CINAHL, and Cochrane databases were reviewed for all studies reporting on SCI and published after 1992. A meta-analysis was conducted using the DerSimonian and Laird (random-effects) model with a summary odds ratio analysis.

RESULTS

Eleven RCTs and 9 observational studies were included in the final analysis. Overall, the 20 included studies reported on 1162 patients with ASIA A injuries. The overall conversion rate was 28.1%, with 327 of 1162 patients improving to at least ASIA B. The overall rate of conversion noted in cervical spine injuries was 33.3%, whereas that in thoracic injuries was 30.6%. Patients undergoing early surgery had a higher rate of conversion (46.1%) than patients undergoing late surgery (25%) (OR 2.31, 95% CI 1.08–4.96, p = 0.03).

CONCLUSIONS

The overall rate of conversion of ASIA A SCIs from pooled data of prospective trials and observational series is 28.1%. This rate of conversion is higher than what is reported in the literature. Early surgery is predictive of a higher conversion rate. However, there are not enough data to provide conclusions pertaining to the efficacy of biological and medical therapies.

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Nader S. Dahdaleh, Cort D. Lawton, Tarek Y. El Ahmadieh, Alexander T. Nixon, Najib E. El Tecle, Sanders Oh, Richard G. Fessler and Zachary A. Smith

Object

Evidence-based medicine is used to examine the current treatment options, timing of surgical intervention, and prognostic factors in the management of patients with traumatic central cord syndrome (TCCS).

Methods

A computerized literature search of the National Library of Medicine database, Cochrane database, and Google Scholar was performed for published material between January 1966 and February 2013 using key words and Medical Subject Headings. Abstracts were reviewed and selected, with the articles segregated into 3 main categories: surgical versus conservative management, timing of surgery, and prognostic factors. Evidentiary tables were then assembled, summarizing data and quality of evidence (Classes I–III) for papers included in this review.

Results

The authors compiled 3 evidentiary tables summarizing 16 studies, all of which were retrospective in design. Regarding surgical intervention versus conservative management, there was Class III evidence to support the superiority of surgery for patients presenting with TCCS. In regards to timing of surgery, most Class III evidence demonstrated no difference in early versus late surgical management. Most Class III studies agreed that older age, especially age greater than 60–70 years, correlated with worse outcomes.

Conclusions

No Class I or Class II evidence was available to determine the efficacy of surgery, timing of surgical intervention, or prognostic factors in patients managed for TCCS. Hence, there is a need to perform well-controlled prospective studies and randomized controlled clinical trials to further investigate the optimal management (surgical vs conservative) and timing of surgical intervention in patients suffering from TCCS.

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Youssef J. Hamade, Najib E. El Tecle, Samer G. Zammar, Tarek Y. El Ahmadieh, Byron K. Yip and Bernard R. Bendok

We report the case of a 62-year-old female who presented for stent-assistant coiling of an incidental 11-mm complex bilobed left superior hypophyseal internal carotid artery aneurysm. A microcatheter was navigated into the aneurysm and trapped by a 37-mm stent. Using three-dimensional and two-dimensional coils, the elongated aneurysm was coiled. The bigger lobe was coiled first followed by the smaller lobe. Minimal residual filling of the smaller lobe will be re-evaluated at 6-month follow up. The patient tolerated the procedure well and no complications were encountered.

The video can be found here: http://youtu.be/TrXfsaICQVo.

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Salah G. Aoun, Tarek Y. El Ahmadieh, Najib E. El Tecle, Marc R. Daou, Joseph G. Adel, Christine S. Park, H. Hunt Batjer and Bernard R. Bendok

OBJECT

Microsurgical skills remain an integral component of neurosurgical education. There is a need for an objective scale to assess microsurgical skills. The objective of this study was to assess the face and construct validity of a benchtraining microanastomosis module and an objective assessment scale, i.e., the Northwestern Objective Microanastomosis Assessment Tool (NOMAT).

METHODS

Medical students, neurosurgical residents, and postdoctoral research fellows at Northwestern University were enrolled in the study. Trainees were divided into 3 groups based on microsurgical experience: 1) experienced, 2) exposed, and 3) novices. Each trainee completed two end-to-end microanastomoses using a 1-mm and a 3-mm synthetic vessel. Two cameras were installed to capture procedural footage. One neurosurgeon blindly graded the performance of trainees using both objective and subjective methods to assess construct validity. Two neurosurgeons reviewed the contents of the simulation module to assess face validity.

RESULTS

Twenty-one trainees participated in the study, including 6 experienced, 6 exposed, and 9 novices. The mean NOMAT score for experienced trainees on the 1-mm module was 47.3/70 compared with 26.0/70 and 25.8/70 for exposed and novice trainees, respectively (p = 0.02). Using subjective grading, experienced trainees performed significantly better on the 1-mm module (64.2/100) compared with exposed or novice trainees (23.3/100 and 25.0/100, respectively; p = 0.02). No statistical difference between groups was noted for the 3-mm module with both NOMAT and subjective grading. Experienced trainees took less time to perform both tasks compared with the others.

CONCLUSIONS

Face and construct validities of the microanastomosis module were established. The scale and the microanastomosis module could help assess the microsurgical skills of neurosurgical trainees and serve as a basis for the creation of a microsurgical curriculum.

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Salah G. Aoun, Valery Peinado Reyes, Tarek Y. El Ahmadieh, Matthew Davies, Ankur R. Patel, Vin Shen Ban, Aaron Plitt, Najib E. El Tecle, Jessica R. Moreno, Jack Raisanen and Carlos A. Bagley

OBJECTIVE

Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications.

METHODS

A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported.

RESULTS

The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT).

CONCLUSIONS

There are still insufficient data to support stem cell injections for back pain. Additional RCTs with long-term follow-up are necessary before statements can be made regarding the efficacy and safety.