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Sherman C. Stein, Neil R. Malhotra and Mark G. Burnett

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R. Carter Clement, Brendan G. Carr, Michael J. Kallan, Catherine Wolff, Patrick M. Reilly and Neil R. Malhotra

Object

A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers.

Methods

The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression.

Results

In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6–11, 12–23, 24–59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29–0.68), 0.56 (0.38–0.81), 0.63 (0.44–0.90), and 0.59 (0.41–0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay.

Conclusions

A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.

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Bradley C. Lega, Shabbar F. Danish, Neil R. Malhotra, Seema S. Sonnad and Sherman C. Stein

Object

Chronic subdural hematoma (CSDH), a condition much more common in the elderly, presents an increasing challenge as the population ages. Treatment strategies for CSDH include bur-hole craniostomy (BHC), twist-drill craniostomy (TDC), and craniotomy. Decision analysis was used to organize existing data and develop recommendations for effective treatment.

Methods

A Medline search was used to identify articles about treatment of CSDH. Direct assessment by health care professionals of the relative health impact of common complications and recurrences was used to generate utility values for treatment outcomes. Monte Carlo simulation and sensitivity analyses allowed comparisons across treatment strategies. A second simulation examined whether intraoperative irrigation or postoperative drainage affect the outcomes following BHC.

Results

On a scale from 0 to 1, the utility of BHC was found to be 0.9608, compared with 0.9202 for TDC (p = 0.001) and 0.9169 for craniotomy (p = 0.006). Sensitivity analysis confirmed the robustness of these values. Craniotomy yielded fewer recurrences, but more frequent and more serious complications than did BHC. There were no significant differences for BHC with or without irrigation or postoperative drainage.

Conclusions

Bur-hole craniostomy is the most efficient choice for surgical drainage of uncomplicated CSDH. Bur-hole craniostomy balances a low recurrence rate with a low incidence of highly morbid complications. Decision analysis provides statistical and empirical guidance in the absence of well-controlled large trials and despite a confusing range of previously reported morbidity and recurrence.

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Dmitriy Petrov, Michael Spadola, Connor Berger, Gregory Glauser, Ahmad F. Mahmoud, Bert O’Malley and Neil R. Malhotra

Chordomas are rare, locally aggressive neoplasms that develop from remnants of the notochord. The typical approach to chordomas of the clivus and axial cervical spine often limits successful en bloc resection. In this case report, authors describe the first-documented transoral approach using both transoral robotic surgery (TORS) for exposure and the Sonopet bone scalpel under navigational guidance to achieve en bloc resection of a cervical chordoma. This 27-year-old man had no significant past medical history (Charlson Comorbidity Index 0). During a trauma workup following a motor vehicle collision, a CT of the patient’s cervical spine demonstrated an incidental 2.2-cm lesion situated along the posterior aspect of the C2 vertebral body. Postoperative imaging showed successful en bloc resection with adequate placement of hardware, and the pathology report demonstrated negative resection margins. The patient tolerated the procedure well, and because of the successful en bloc resection, radiation has been deferred. At 7 months postoperatively, the patient returned to work in New York City. Contrasted MRI at 15 months postoperatively showed the patient to be disease free. This approach offers a promising way forward in the treatment of these complex tumors.

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Luis Perez-Orribo, Laura A. Snyder, Samuel Kalb, Ali M. Elhadi, Forrest Hsu, Anna G. U. S. Newcomb, Devika Malhotra, Neil R. Crawford and Nicholas Theodore

OBJECTIVE

Craniovertebral junction (CVJ) injuries complicated by transverse atlantal ligament (TAL) disruption often require surgical stabilization. Measurements based on the atlantodental interval (ADI), atlas lateral diameter (ALD1), and axis lateral diameter (ALD2) may help clinicians identify TAL disruption. This study used CT scanning to evaluate the reliability of these measurements and other variants in the clinical setting.

METHODS

Patients with CVJ injuries treated at the authors' institution between 2004 and 2011 were evaluated retrospectively for demographics, mechanism and location of CVJ injury, classification of injury, treatment, and modified Japanese Orthopaedic Association score at the time of injury and follow-up. The integrity of the TAL was evaluated using MRI. The ADI, ALD1, and ALD2 were measured on CT to identify TAL disruption indirectly.

RESULTS

Among the 125 patients identified, 40 (32%) had atlas fractures, 59 (47.2%) odontoid fractures, 31 (24.8%) axis fractures, and 4 (3.2%) occipital condyle fractures. TAL disruption was documented on MRI in 11 cases (8.8%). The average ADI for TAL injury was 1.8 mm (range 0.9–3.9 mm). Nine (81.8%) of the 11 patients with TAL injury had an ADI of less than 3 mm. In 10 patients (90.9%) with TAL injury, overhang of the C-1 lateral masses on C-2 was less than 7 mm. ADI, ALD1, ALD2, ALD1 – ALD2, and ALD1/ALD2 did not correlate with the integrity of the TAL.

CONCLUSIONS

No current measurement method using CT, including the ADI, ALD1, and ALD2 or their differences or ratios, consistently indicates the integrity of the TAL. A more reliable CT-based criterion is needed to diagnose TAL disruption when MRI is unavailable.

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Jared M. Pisapia, Nikhil R. Nayak, Ryan D. Salinas, Luke Macyszyn, John Y. K. Lee, Timothy H. Lucas, Neil R. Malhotra, H. Isaac Chen and James M. Schuster

OBJECTIVE

As odontoid process fractures become increasingly common in the aging population, a technical understanding of treatment approaches is critical. 3D image guidance can improve the safety of posterior cervical hardware placement, but few studies have explored its utility in anterior approaches. The authors present in a stepwise fashion the technique of odontoid screw placement using the Medtronic O-arm navigation system and describe their initial institutional experience with this surgical approach.

METHODS

The authors retrospectively reviewed all cases of anterior odontoid screw fixation for Type II fractures at an academic medical center between 2006 and 2015. Patients were identified from a prospectively collected institutional database of patients who had suffered spine trauma. A standardized protocol for navigated odontoid screw placement was generated from the collective experience at the authors' institution. Secondarily, the authors compared collected variables, including presenting symptoms, injury mechanism, surgical complications, blood loss, operative time, radiographically demonstrated nonunion rate, and clinical outcome at most recent follow-up, between navigated and nonnavigated cases.

RESULTS

Ten patients (three female; mean age 61) underwent odontoid screw placement. Most patients presented with neck pain without a neurological deficit after a fall. O-arm navigation was used in 8 patients. An acute neck hematoma and screw retraction, each requiring surgery, occurred in 2 patients in whom navigation was used. Partial vocal cord paralysis occurred after surgery in one patient in whom no navigation was used. There was no difference in blood loss or operative time with or without navigation. One patient from each group had radiographic nonunion. No patient reported a worsening of symptoms at follow-up (mean duration 9 months).

CONCLUSIONS

The authors provide a detailed step-by-step guide to the navigated placement of an odontoid screw. Their surgical experience suggests that O-arm–assisted odontoid screw fixation is a viable approach. Future studies will be needed to rigorously compare the accuracy and efficiency of navigated versus nonnavigated odontoid screw placement.

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Luis Perez-Orribo, Samuel Kalb, Laura A. Snyder, Forrest Hsu, Devika Malhotra, Richard D. Lefevre, Ali M. Elhadi, Anna G. U. S. Newcomb, Nicholas Theodore and Neil R. Crawford

OBJECTIVE

The rule of Spence is inaccurate for assessing integrity of the transverse atlantal ligament (TAL). Because CT is quick and easy to perform at most trauma centers, the authors propose a novel sequence of obtaining 2 CT scans to improve the diagnosis of TAL impairment. The sensitivity of a new CT-based method for diagnosing a TAL injury in a cadaveric model was assessed.

METHODS

Ten human cadaveric occipitocervical specimens were mounted horizontally in a supine posture with wooden inserts attached to the back of the skull to maintain a neutral or flexed (10°) posture. Specimens were scanned in neutral and flexed postures in a total of 4 conditions (3 conditions in each specimen): 1) intact (n = 10); either 2A) after a simulated Jefferson fracture with an intact TAL (n = 5) or 2B) after a TAL disruption with no Jefferson fracture (n = 5); and 3) after TAL disruption and a simulated Jefferson fracture (n = 10). The atlantodental interval (ADI) and cross-sectional canal area were measured.

RESULTS

From the neutral to the flexed posture, ADI increased an average of 2.5% in intact spines, 6.25% after a Jefferson fracture without TAL disruption, 34% after a TAL disruption without fracture, and 25% after TAL disruption with fracture. The increase in ADI was significant with both TAL disruption and TAL disruption and fracture (p < 0.005) but not in the other 2 conditions (p > 0.6). Changes in spinal canal area were not significant (p > 0.70).

CONCLUSIONS

This novel method was more sensitive than the rule of Spence for evaluating the integrity of the TAL on CT and does not increase the risk of further neurological damage.

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Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Nikhil Sharma, Matthew Piazza, Paul J. Marcotte, William Welch, Ali K. Ozturk, H. Isaac Chen, Zarina S. Ali, James Schuster and Neil R. Malhotra

OBJECTIVE

Healthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors’ objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.

METHODS

The authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient’s chart and the hospital’s billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score–matching analysis to compare the two cohorts (n = 180).

RESULTS

Direct hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score–matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).

CONCLUSIONS

Both SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.

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Peter Syre III, Leonardo Rodriguez-Cruz, Rajiv Desai, Karl A. Greene, Robert Hurst, James Schuster, Neil R. Malhotra and Paul Marcotte

Object

Gunshot wounds to the atlantoaxial spine are uncommon injuries and rarely require treatment, as a bullet traversing this segment often results in a fatal injury. Additionally, these injuries are typically biomechanically stable. The authors report a series of 10 patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex. Their care is discussed and conclusions are drawn from these cases to identify the optimal treatment for these injuries.

Methods

A retrospective review was conducted of patients presenting to the emergency rooms of 3 institutions with gunshot wounds involving the atlantoaxial spine. Mechanism of injury and neurological status were obtained, as was the extent of the osteoligamentous, vascular, and neurological injuries. Nonoperative and operative treatment, complications, and clinical and radiographic outcome were recorded. The data were then analyzed to determine the neurological and biomechanical prognosis of these injuries, the utility of the various diagnostic modalities in the acute management of the injuries, and the nature and effectiveness of the nonoperative and operative treatment modalities.

Results

Ten patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex were identified. All but 2 patients sustained a vertebral artery injury. Each patient was evaluated using cervical radiographs, CT scans, and vascular imaging, 8 in the form of digital subtraction angiography and 2 with high-resolution CT angiography. Uncomplicated patients were treated conservatively using cervical collar immobilization, local wound care, and antibiotics. One patient was treated using a halo for instability and 1 underwent posterior fusion following a posterolateral decompression for delayed myelopathy. One patient underwent transoral resection of a bullet fragment. One patient underwent embolization for a symptomatic arteriovenous fistula and a second patient underwent a neck exploration and a jugular vein ligation. None of the patients received anticoagulation therapy. The mean follow-up duration was 13 months. All but 2 patients regained their previous functional status and all ultimately attained a mechanically stable spine.

Conclusions

These 10 patients represent a rare form of cervical spine penetrating injury. Unilateral gunshot wounds to the atlantoaxial complex are usually stable and the need for acute surgical intervention is rare. Unilateral vertebral artery injury is well tolerated and any information provided by angiography does not alter the acute management of the patient. Vascular complications from gunshot wounds can be managed effectively by endovascular techniques.

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Matthew R. Sanborn, Jayesh P. Thawani, Robert G. Whitmore, Michael Shmulevich, Benjamin Hardy, Conrad Benedetto, Neil R. Malhotra, Paul Marcotte, William C. Welch, Stephen Dante and Sherman C. Stein

Object

There is considerable variation in the use of adjunctive technologies to confirm pedicle screw placement. Although there is literature to support the use of both neurophysiological monitoring and isocentric fluoroscopy to confirm pedicle screw positioning, there are no studies examining the cost-effectiveness of these technologies. This study compares the cost-effectiveness and efficacy of isocentric O-arm fluoroscopy, neurophysiological monitoring, and postoperative CT scanning after multilevel instrumented fusion for degenerative lumbar disease.

Methods

Retrospective data were collected from 4 spine surgeons who used 3 different strategies for monitoring of pedicle screw placement in multilevel lumbar degenerative disease. A decision analysis model was developed to analyze costs and outcomes of the 3 different monitoring strategies. A total of 448 surgeries performed between 2005 and 2010 were included, with 4 cases requiring repeat operation for malpositioned screws. A sample of 64 of these patients was chosen for structured interviews in which the EuroQol-5D questionnaire was used. Expected costs and quality-adjusted life years were calculated based on the incidence of repeat operation and its negative effect on quality of life and costs.

Results

The decision analysis model demonstrated that the O-arm monitoring strategy is significantly (p < 0.001) less costly than the strategy of postoperative CT scanning following intraoperative uniplanar fluoroscopy, which in turn is significantly (p < 0.001) less costly than neurophysiological monitoring. The differences in effectiveness of the different monitoring strategies are not significant (p = 0.92).

Conclusions

Use of the O-arm for confirming pedicle screw placement is the least costly and therefore most cost-effective strategy of the 3 techniques analyzed.