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Ahmed Jorge, Michael D. White and Nitin Agarwal

OBJECTIVE

Individuals with a spinal cord injury (SCI) in socioeconomically disadvantaged settings (e.g., rural or low income) have different outcomes than their counterparts; however, a contemporary literature review identifying and measuring these outcomes has not been published. Here, the authors’ aim was to perform a systematic review and identify these parameters in the hope of providing tangible targets for future clinical research efforts.

METHODS

A systematic review was performed to find English-language articles published from 2007 to 2017 in the PubMed/MEDLINE, EMBASE, and SCOPUS databases. Studies evaluating any outcomes related to patients with an SCI and in a low-resource setting were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and a flowchart was created. Of the 403 articles found, 31 underwent complete review and 26 were eligible for study inclusion. According to the current study criteria, any case studies, studies in less developed countries, studies including and not separating other types of neurological disorders, studies not assessing the effects of a low-resource setting on outcomes in patients with SCI, and studies evaluating the causes of SCI in a low-resource setting were excluded.

RESULTS

In SCI patients, a lower income was a predictor of death (OR 2.1, 95% CI 1.7–2.6, p = 0.0002). Moreover, secondary outcomes such as pain intensities (OR 3.32, 95% CI 2.21–4.49, p < 0.001), emergency room visits (11% more likely, p = 0.006), and pressure ulcer formation (OR 2.1, 95% CI 1.5–3.0, p < 0.001) were significantly higher in the lower income brackets. Rurality was also a factor and was significantly associated with increased emergency room visits (OR 1.5, 95% CI 1.1–2.1, p = 0.01) and lower outpatient service utilization (incidence rate ratio [IRR] 0.57, 95% CI 0.35–0.93, p < 0.05).

CONCLUSIONS

The authors showed that individuals in a low-resource setting who have suffered an SCI have significantly different outcomes than their counterparts. These specific outcomes are promising targets for future research efforts that focus on improving health conditions among this population.

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Nitin Agarwal, Robert F. Heary and Prateek Agarwal

OBJECTIVE

Pedicle screw fixation is a technique widely used to treat conditions ranging from spine deformity to fracture stabilization. Pedicle screws have been used traditionally in the lumbar spine; however, they are now being used with increasing frequency in the thoracic spine as a more favorable alternative to hooks, wires, or cables. Although safety concerns, such as the incidence of adjacent-segment disease (ASD) after cervical and lumbar fusions, have been reported, such issues in the thoracic spine have yet to be addressed thoroughly. Here, the authors review the literature on ASD after thoracic pedicle screw fixation and report their own experience specifically involving the use of pedicle screws in the thoracic spine.

METHODS

Select references from online databases, such as PubMed (provided by the US National Library of Medicine at the National Institutes of Health), were used to survey the literature concerning ASD after thoracic pedicle screw fixation. To include the authors’ experience at Rutgers New Jersey Medical School, a retrospective review of a prospectively maintained database was performed to determine the incidence of complications over a 13-year period in 123 consecutive adult patients who underwent thoracic pedicle screw fixation. Children, pregnant or lactating women, and prisoners were excluded from the review. By comparing preoperative and postoperative radiographic images, the occurrence of thoracic ASD and disease within the surgical construct was determined.

RESULTS

Definitive radiographic fusion was detected in 115 (93.5%) patients. Seven incidences of instrumentation failure and 8 lucencies surrounding the screws were observed. One patient was observed to have ASD of the thoracic spine. The mean follow-up duration was 50 months.

CONCLUSIONS

This long-term radiographic evaluation revealed the use of pedicle screws for thoracic fixation to be an effective stabilization modality. In particular, ASD seems to be less of a problem in the relatively immobile thoracic spine than in the more mobile cervical and lumbar spines.

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A longitudinal survey of adult spine and peripheral nerve case entries during neurosurgery residency training

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

Nitin Agarwal, Michael D. White and D. Kojo Hamilton

OBJECTIVE

Currently, there is a lack of research assessing residents’ operative experience and caseload variability. The current study utilizes data from the Accreditation Council for Graduate Medical Education (ACGME) case log system to analyze national trends in neurosurgical residents’ exposure to adult spinal procedures.

METHODS

Prospectively populated ACGME resident case logs from 2013 to 2017 were retrospectively reviewed. The reported number of spinal procedures was compared to the ACGME minimum requirements for each surgical category pertaining to adult spine surgery. A linear regression analysis was conducted to identify changes in operative caseload by residents graduating during the study period, as well as a one-sample t-test using IBM SPSS software to compare the mean number of procedures in each surgical category to the ACGME required minimums.

RESULTS

A mean of 427.42 total spinal procedures were performed throughout residency training for each of the 877 residents graduating between 2013 and 2017. The mean number of procedures completed by graduating residents increased by 19.96 (r2 = 0.95) cases per year. The number of cases in every procedural subspecialty, besides peripheral nerve operations, significantly increased during this time. The two procedural categories with the largest changes were anterior and posterior cervical approaches for decompression/stabilization, which increased by 8.78% per year (r2 = 0.95) and 9.04% per year (r2 = 0.95), respectively. There was also a trend of increasing cases logged for lead resident surgeons and a decline in cases logged for senior resident surgeons. Residents’ mean caseloads during residency were found to be vastly greater than the ACGME required minimums: residents performed at least twice as many procedures as the required minimums in every surgical category.

CONCLUSIONS

Graduating neurosurgical residents reported increasing case volumes for adult spinal cases during this 5-year interval. An increase in logged cases for lead resident surgeons as opposed to senior resident surgeons indicates that residents were logging more cases in which they had a more critical role in the procedure. Moreover, the average resident was noted to perform more than twice the number of procedures required by the ACGME in every surgical category, indicating that neurosurgical residents are getting greater exposure to spine surgery than expected. Given the known correlation between case volume and improved surgical outcomes, this data demonstrates each graduating neurosurgical residency class experiences an augmented training in spine surgery.

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Nitin Agarwal, Michael D. White, Susan C. Pannullo and Lola B. Chambless

OBJECTIVE

Resident attrition creates a profound burden on trainees and residency programs. This study aims to analyze trends in resident attrition in neurological surgery.

METHODS

This study followed a cohort of 1275 residents who started neurosurgical residency from 2005 to 2010. Data obtained from the American Association of Neurological Surgeons (AANS) included residents who matched in neurosurgery during this time. Residents who did not finish their residency training at the program in which they started were placed into the attrition group. Residents in the attrition group were characterized by one of five outcomes: transferred neurosurgery programs; transferred to a different specialty; left clinical medicine; deceased; or unknown. A thorough internet search was conducted for residents who did not complete their training at their first neurosurgical program. Variables leading to attrition were also analyzed, including age, sex, presence of advanced degree (Ph.D.), postgraduate year (PGY), and geographical region of program.

RESULTS

Residents starting neurosurgical residency from 2005 to 2010 had an overall attrition rate of 10.98%. There was no statistically significant difference in attrition rates among the years (p = 0.337). The outcomes for residents in the attrition group were found to be as follows: 33.61% transferred neurosurgical programs, 56.30% transferred to a different medical specialty, 8.40% left clinical medicine, and 1.68% were deceased. It was observed that women had a higher attrition rate (18.50%) than men (10.35%). Most attrition (65.07%) occurred during PGY 1 or 2. The attrition group was also observed to be significantly older at the beginning of residency training, with a mean of 31.69 years of age compared to 29.31 in the nonattrition group (p < 0.001). No significant difference was observed in the attrition rates for residents with a Ph.D. (9.86%) compared to those without a Ph.D. (p = 0.472).

CONCLUSIONS

A majority of residents in the attrition group pursued training in different medical specialties, most commonly neurology, radiology, and anesthesiology. Factors associated with an increased rate of attrition were older age at the beginning of residency, female sex, and junior resident (PGY-1 to PGY-2). Resident attrition remains a significant problem within neurosurgical training, and future studies should focus on targeted interventions to identify individuals at risk to help them succeed in their medical careers.

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Robert F. Heary, Ira M. Goldstein, Katarzyna M. Getto and Nitin Agarwal

Cervical disc arthroplasty (CDA) has been gaining popularity as a surgical alternative to anterior cervical discectomy and fusion. Spontaneous fusion following a CDA is uncommon. A few anecdotal reports of heterotrophic ossification around the implant sites have been noted for the BRYAN, ProDisc-C, Mobi-C, PRESTIGE, and PCM devices. All CDA fusions reported to date have been in devices that are semiconstrained.

The authors reported the case of a 56-year-old man who presented with left C-7 radiculopathy and neck pain for 10 weeks after an assault injury. There was evidence of disc herniation at the C6–7 level. He was otherwise healthy with functional scores on the visual analog scale (VAS, 4.2); neck disability index (NDI, 16); and the 36-item short form health survey (SF-36; physical component summary [PSC] score 43 and mental component summary [MCS] score 47). The patient underwent total disc replacement in which the DISCOVER Artificial Cervical Disc (DePuy Spine, Inc.) was used. The patient was seen at regular follow-up visits up to 60 months. At his 60-month follow-up visit, he had complete radiographic fusion at the C6–7 level with bridging trabecular bone and no motion at the index site on dynamic imaging. He was pain free, with a VAS score of 0, NDI score of 0, and SF-36 PCS and MCS scores of 61 and 55, respectively.

Conclusions

This is the first case report that identifies the phenomenon of fusion around a nonconstrained cervical prosthesis. Despite this unwanted radiographic outcome, the patient's clinical outcome was excellent.

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Nitin Agarwal, Michael D. White, Jonathan Cohen, L. Dade Lunsford and D. Kojo Hamilton

OBJECTIVE

The purpose of this study was to analyze national trends in adult cranial cases performed by neurological surgery residents as logged into the Accreditation Council for Graduate Medical Education (ACGME) system.

METHODS

The ACGME resident case logs were retrospectively reviewed for the years 2009–2017. In these reports, the national average of cases performed by graduating residents is organized by year, type of procedure, and level of resident. These logs were analyzed in order to evaluate trends in residency experience with adult cranial procedures. The reported number of cranial procedures was compared to the ACGME neurosurgical minimum requirements for each surgical category. A linear regression analysis was conducted in order to identify changes in the average number of procedures performed by residents graduating during the study period. Additionally, a 1-sample t-test was performed to compare reported case volumes to the ACGME required minimums.

RESULTS

An average of 577 total cranial procedures were performed throughout residency training for each of the 1631 residents graduating between 2009 and 2017. The total caseload for graduating residents upon completion of training increased by an average of 26.59 cases each year (r2 = 0.99). Additionally, caseloads in most major procedural subspecialty categories increased; this excludes open vascular and extracranial vascular categories, which showed, respectively, a decrease and no change. The majority of cranial procedures performed throughout residency pertained to tumor (mean 158.38 operations), trauma (mean 102.17 operations), and CSF diversion (mean 76.12 operations). Cranial procedures pertaining to the subspecialties of trauma and functional neurosurgery showed the greatest rise in total procedures, increasing at 8.23 (r2 = 0.91) and 6.44 (r2 = 0.95) procedures per graduating year, respectively.

CONCLUSIONS

Neurosurgical residents reported increasing case volumes for most cranial procedures between 2009 and 2017. This increase was observed despite work hour limitations set forth in 2003 and 2011. Of note, an inverse relationship between open vascular and endovascular procedures was observed, with a decrease in open vascular procedures and an increase in endovascular procedures performed during the study period. When compared to the ACGME required minimums, neurosurgery residents gained much more exposure to cranial procedures than was expected. Additionally, a larger caseload throughout training suggests that residents are graduating with greater competency and experience in cranial neurosurgery.

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Vamsi Reddy, Arjun Gupta, Michael D. White, Raghav Gupta, Prateek Agarwal, Arpan V. Prabhu, Bryan Lieber, Yue-Fang Chang and Nitin Agarwal

OBJECTIVE

Publication metrics such as the Hirsch index (h-index) are often used to evaluate and compare research productivity in academia. The h-index is not a field-normalized statistic and can therefore be dependent on overall rates of publication and citation within specific fields. Thus, a metric that adjusts for this while measuring individual contributions would be preferable. The National Institutes of Health (NIH) has developed a new, field-normalized, article-level metric called the “relative citation ratio” (RCR) that can be used to more accurately compare author productivity between fields. The mean RCR is calculated as the total number of citations per year of a publication divided by the average field-specific citations per year, whereas the weighted RCR is the sum of all article-level RCR scores over an author’s career. The present study was performed to determine how various factors, such as academic rank, career duration, a Doctor of Philosophy (PhD) degree, and sex, impact the RCR to analyze research productivity among academic neurosurgeons.

METHODS

A retrospective data analysis was performed using the iCite database. All physician faculty affiliated with Accreditation Council for Graduate Medical Education (ACGME)–accredited neurological surgery programs were eligible for analysis. Sex, career duration, academic rank, additional degrees, total publications, mean RCR, and weighted RCR were collected for each individual. Mean RCR and weighted RCR were compared between variables to assess patterns of analysis by using SAS software version 9.4.

RESULTS

A total of 1687 neurosurgery faculty members from 125 institutions were included in the analysis. Advanced academic rank, longer career duration, and PhD acquisition were all associated with increased mean and weighted RCRs. Male sex was associated with having an increased weighted RCR but not an increased mean RCR score. Overall, neurological surgeons were highly productive, with a median RCR of 1.37 (IQR 0.93–1.97) and a median weighted RCR of 28.56 (IQR 7.99–85.65).

CONCLUSIONS

The RCR and its derivatives are new metrics that help fill in the gaps of other indices for research output. Here, the authors found that advanced academic rank, longer career duration, and PhD acquisition were all associated with increased mean and weighted RCRs. Male sex was associated with having an increased weighted, but not mean, RCR score, most likely because of historically unequal opportunities for women within the field. Furthermore, the data showed that current academic neurosurgeons are exceptionally productive compared to both physicians in other specialties and the general scientific community.

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Nitin Agarwal, Ahmed Kashkoush, Michael M. McDowell, William R. Lariviere, Naveed Ismail and Robert M. Friedlander

OBJECTIVE

Ventricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type—fixed versus programmable—on shunt durability and cost for placement of shunts in adult patients.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.

RESULTS

A total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6–1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938–$3876) and $1504 (interquartile range $753–$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2–3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2–2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.

CONCLUSIONS

Long-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.

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Lateral lumbar interbody fusion in the elderly: a 10-year experience

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

Nitin Agarwal, Andrew Faramand, Nima Alan, Zachary J. Tempel, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Elderly patients, often presenting with multiple medical comorbidities, are touted to be at an increased risk of peri- and postoperative complications following spine surgery. Various minimally invasive surgical techniques have been developed and employed to treat an array of spinal conditions while minimizing complications. Lateral lumbar interbody fusion (LLIF) is one such approach. The authors describe clinical outcomes in patients over the age of 70 years following stand-alone LLIF.

METHODS

A retrospective query of a prospectively maintained database was performed for patients over the age of 70 years who underwent stand-alone LLIF. Patients with posterior segmental fixation and/or fusion were excluded. The preoperative and postoperative values for the Oswestry Disability Index (ODI) were analyzed to compare outcomes after intervention. Femoral neck t-scores were acquired from bone density scans and correlated with the incidence of graft subsidence.

RESULTS

Among the study cohort of 55 patients, the median age at the time of surgery was 74 years (range 70–87 years). Seventeen patients had at least 3 medical comorbidities at surgery. Twenty-three patients underwent a 1-level, 14 a 2-level, and 18 patients a 3-level or greater stand-alone lateral fusion. The median estimated blood loss was 25 ml (range 5–280 ml). No statistically significant relationship was detected between volume of blood loss and the number of operative levels. The median length of hospital stay was 2 days (range 1–4 days). No statistically significant relationship was observed between the length of hospital stay and age at the time of surgery. There was one intraoperative death secondary to cardiac arrest, with a mortality rate of 1.8%. One patient developed a transient femoral nerve injury. Five patients with symptomatic graft subsidence subsequently underwent posterior instrumentation. A lower femoral neck t-score < −1.0 correlated with a higher incidence of graft subsidence (p = 0.006). The mean ODI score 1 year postoperatively of 31.1 was significantly (p = 0.003) less than the mean preoperative ODI score of 46.2.

CONCLUSIONS

Stand-alone LLIF can be safely and effectively performed in the elderly population. Careful evaluation of preoperative bone density parameters should be employed to minimize risk of subsidence and need for additional surgery. Despite an association with increased comorbidities, age alone should not be a deterrent when considering stand-alone LLIF in the elderly population.