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Praveen V. Mummaneni, Valli P. Mummaneni, Regis W. Haid Jr., Gerald E. Rodts Jr. and Rick C. Sasso

The correction of chin-on-chest deformity is challenging and requires combined anterior and posterior approaches to the cervical spine. The authors describe a cervical osteotomy technique for the correction of chin-on-chest deformity in patients with ankylosing spondylitis (AS). This procedure can be accomplished using a posterior screw rod construct combined with an anterior hybrid plate system.

In patients with AS, a “front-back-front” approach may be necessary because of the deformity's rigidity. The authors describe the complicated intubation and anesthetic requirements for this approach. They performed an anterior discectomy, cervical osteotomy, and unilateral pediculectomy but did not place anterior instrumentation. Via a posterior approach, laminectomies, facetectomies, and the contralateral pediculectomy were then undertaken. A posterior cervical screw/rod system was placed and loosely connected to titanium rods. Intraoperatively the deformity was corrected by placing the neck in extension combined with compression of the posterior screws on the rods. The posterior construct is then tightened. Finally, an anterior cervical approach is performed to place a structural interbody graft and a hybrid anterior cervical plate construct.

The authors have successfully used this approach to correct a chin-on-chest deformity in a patient with ankylosing spondylitis. At 1-year follow-up examination, excellent resolution of the deformity and solid fusion had been achieved. They prefer to perform this procedure by using state-of-the-art anterior and posterior instrumentation systems.

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John E. Ziewacz, Sigurd H. Berven, Valli P. Mummaneni, Tsung-Hsi Tu, Olaolu C. Akinbo, Russ Lyon and Praveen V. Mummaneni

Object

The purpose of this study was to provide an evidence-based algorithm for the design, development, and implementation of a new checklist for the response to an intraoperative neuromonitoring alert during spine surgery.

Methods

The aviation and surgical literature was surveyed for evidence of successful checklist design, development, and implementation. The limitations of checklists and the barriers to their implementation were reviewed. Based on this review, an algorithm for neurosurgical checklist creation and implementation was developed. Using this algorithm, a multidisciplinary team surveyed the literature for the best practices for how to respond to an intraoperative neuromonitoring alert. All stakeholders then reviewed the evidence and came to consensus regarding items for inclusion in the checklist.

Results

A checklist for responding to an intraoperative neuromonitoring alert was devised. It highlights the specific roles of the anesthesiologist, surgeon, and neuromonitoring personnel and encourages communication between teams. It focuses on the items critical for identifying and correcting reversible causes of neuromonitoring alerts. Following initial design, the checklist draft was reviewed and amended with stakeholder input. The checklist was then evaluated in a small-scale trial and revised based on usability and feasibility.

Conclusions

The authors have developed an evidence-based algorithm for the design, development, and implementation of checklists in neurosurgery and have used this algorithm to devise a checklist for responding to intraoperative neuromonitoring alerts in spine surgery.

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Praveen V. Mummaneni, John F. Burke, Andrew K. Chan, Julie Ann Sosa, Errol P. Lobo, Valli P. Mummaneni, Sheila Antrum, Sigurd H. Berven, Michael S. Conte, Sarah B. Doernberg, Andrew N. Goldberg, Christopher P. Hess, Steven W. Hetts, S. Andrew Josephson, Maureen P. Kohi, C. Benjamin Ma, Vaikom S. Mahadevan, Annette M. Molinaro, Andrew H. Murr, Sirisha Narayana, John P. Roberts, Marshall L. Stoller, Philip V. Theodosopoulos, Thomas P. Vail, Sandra Wienholz, Michael A. Gropper, Adrienne Green and Mitchel S. Berger

OBJECTIVE

During the COVID-19 pandemic, quaternary-care facilities continue to provide care for patients in need of urgent and emergent invasive procedures. Perioperative protocols are needed to streamline care for these patients notwithstanding capacity and resource constraints.

METHODS

A multidisciplinary panel was assembled at the University of California, San Francisco, with 26 leaders across 10 academic departments, including 7 department chairpersons, the chief medical officer, the chief operating officer, infection control officers, nursing leaders, and resident house staff champions. An epidemiologist, an ethicist, and a statistician were also consulted. A modified two-round, blinded Delphi method based on 18 agree/disagree statements was used to build consensus. Significant disagreement for each statement was tested using a one-sided exact binomial test against an expected outcome of 95% consensus using a significance threshold of p < 0.05. Final triage protocols were developed with unblinded group-level discussion.

RESULTS

Overall, 15 of 18 statements achieved consensus in the first round of the Delphi method; the 3 statements with significant disagreement (p < 0.01) were modified and iteratively resubmitted to the expert panel to achieve consensus. Consensus-based protocols were developed using unblinded multidisciplinary panel discussions. The final algorithms 1) quantified outbreak level, 2) triaged patients based on acuity, 3) provided a checklist for urgent/emergent invasive procedures, and 4) created a novel scoring system for the allocation of personal protective equipment. In particular, the authors modified the American College of Surgeons three-tiered triage system to incorporate more urgent cases, as are often encountered in neurosurgery and spine surgery.

CONCLUSIONS

Urgent and emergent invasive procedures need to be performed during the COVID-19 pandemic. The consensus-based protocols in this study may assist healthcare providers to optimize perioperative care during the pandemic.