Nicholas Theodore | Johns Hopkins University School of Medicine (original) (raw)

Papers by Nicholas Theodore

Journal of Neurosurgery: Spine

OBJECTIVE The authors systematically reviewed current evidence for the utility of mean arterial p... more OBJECTIVE The authors systematically reviewed current evidence for the utility of mean arterial pressure (MAP), intraspinal pressure (ISP), and spinal cord perfusion pressure (SCPP) as predictors of outcomes after traumatic spinal cord injury (SCI). METHODS PubMed, Cochrane Reviews Library, EMBASE, and Scopus databases were queried in December 2020. Two independent reviewers screened articles using Covidence software. Disagreements were resolved by a third reviewer. The inclusion criteria for articles were 1) available in English; 2) full text; 3) clinical studies on traumatic SCI interventions; 4) involved only human participants; and 5) focused on MAP, ISP, or SCPP. Exclusion criteria were 1) only available in non-English languages; 2) focused only on the brain; 3) described spinal diseases other than SCI; 4) interventions altering parameters other than MAP, ISP, or SCPP; and 5) animal studies. Studies were analyzed qualitatively and grouped into two categories: interventions incr...

Neurosurgical Focus

OBJECTIVE Damage to the thoracolumbar spine can confer significant morbidity and mortality. The T... more OBJECTIVE Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans. METHODS All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the ...

Comparative effectiveness research has a vital role in recent health reform and policies. Special... more Comparative effectiveness research has a vital role in recent health reform and policies. Specialty training is one of these provider-side variables and surgeons who were trained in different specialties may have different outcomes upon performing the same procedure. The objective of this retrospective 1:1 propensity score-matched cohort study was to investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective posterior/transforaminal lumbar interbody fusion for degenerative spine diseases. 22,176 patients were reviewed from ACS-NSQIP database. Propensity score matching and subgroup analysis were utilized. After controlling for baseline characteristics in both groups (single/multi-level PLIF/TLIF), patients operated on by neurosurgeons were more likely to have longer operation time (239 vs 205 minutes / 276 vs 254 minutes), shorter total hospital stay (75 vs 96 hours / 85 vs 103 hours), lower return to ope...

arXiv: Medical Physics, 2020

Metal artifacts present a frequent challenge to cone-beam CT (CBCT) in image-guided surgery, obsc... more Metal artifacts present a frequent challenge to cone-beam CT (CBCT) in image-guided surgery, obscuring visualization of metal instruments and adjacent anatomy. Recent advances in mobile C-arm systems have enabled 3D imaging capacity with non-circular orbits. We extend a previously proposed metal artifacts avoidance (MAA) method to reduce the influence of metal artifacts by prospectively defining a non-circular orbit that avoids metal-induced biases in projection domain. Accurate geometric calibration is an important challenge to accurate 3D image reconstruction for such orbits. We investigate the performance of interpolation-based calibration from a library of circular orbits for any non-circular orbit. We apply the method to non-circular scans acquired for MAA, which involves: (i) coarse 3D localization of metal objects via only two scout views using an end-to-end trained neural network; (ii) calculation of the metal-induced x-ray spectral shift for all possible views; and (iii) id...

International Journal of Spine Surgery, 2021

Journal of Neurosurgery: Spine, 2021

OBJECTIVE Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in mult... more OBJECTIVE Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in multiple surgical specialties and are recognized for their potential to improve patient outcomes and decrease hospitalization costs. However, they have only recently been applied to spinal surgery. The goal in the present work was to describe the development, implementation, and impact of an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective spine procedures at an academic community hospital. METHODS A multidisciplinary team, drawing on prior publications and spine surgery best practices, collaborated to develop an ERASS protocol. Patients undergoing elective cervical or lumbar procedures were prospectively enrolled at a single tertiary care center; interventions were standardized across the cohort for pre-, intra-, and postoperative care using standardized order sets in the electronic medical record. Protocol efficacy was evaluated by comparing enrolled ...

Journal of Neurosurgery: Spine, 2021

OBJECTIVE Although fellowship training is becoming increasingly common in neurosurgery, it is unc... more OBJECTIVE Although fellowship training is becoming increasingly common in neurosurgery, it is unclear which factors predict an academic career trajectory among spinal neurosurgeons. In this study, the authors sought to identify predictors associated with academic career placement among fellowship-trained neurological spinal surgeons. METHODS Demographic data and bibliometric information on neurosurgeons who completed a residency program accredited by the Accreditation Council for Graduate Medical Education between 1983 and 2019 were gathered, and those who completed a spine fellowship were identified. Employment was denoted as academic if the hospital where a neurosurgeon worked was affiliated with a neurosurgical residency program; all other positions were denoted as nonacademic. A logistic regression model was used for multivariate statistical analysis. RESULTS A total of 376 fellowship-trained spinal neurosurgeons were identified, of whom 140 (37.2%) held academic positions. The ...

Operative Neurosurgery, 2021

The increasing interest and advancements in robotic spine surgery parallels a growing emphasis on... more The increasing interest and advancements in robotic spine surgery parallels a growing emphasis on maximizing patient safety and outcomes. In addition, an increasing interest in minimally invasive spine surgery has further fueled robotic development, as robotic guidance systems are aptly suited for these procedures. This review aims to address 3 of the most critical aspects of robotics in spine surgery today: salient details regarding the current and future development of robotic systems and functionalities, the reported accuracy of implant placement over the years, and how the implementation of robotic systems will impact the training of future generations of spine surgeons. As current systems establish themselves as highly accurate tools for implant placement, the development of novel features, including even robotic-assisted decompression, will likely occur. As spine surgery robots evolve and become increasingly adopted, it is likely that resident and fellow education will follow ...

World Journal of Orthopedics, 2019

BACKGROUND Over 400000 Americans annually undergo spinal fusion surgeries, yet up to 40% of these... more BACKGROUND Over 400000 Americans annually undergo spinal fusion surgeries, yet up to 40% of these procedures result in pseudoarthrosis even with iliac crest autograft, the current "gold standard" treatment. Tissue engineering has the potential to solve this problem via the creation of bone grafts involving bone-promoting growth factors (e.g., bone morphogenetic protein 2). A broad assessment of experimental growth factors is important to inform future work and clinical potential in this area. To date, however, no study has systematically reviewed the investigational growth factors utilized in preclinical animal models of spinal fusion. AIM To review all published studies assessing investigational growth factors for spinal fusion in animal models and identify promising agents for translation. METHODS We conducted a systematic review of the literature using PubMed, Embase, Cochrane Library, and Web of Science databases with searches run on May 29 th , 2018. The search query was designed to include all non-human, preclinical animal models of spinal fusion reported in the literature without a timespan limit. Extracted data for each model included surgical approach, level of fusion, animal species and breed, animal age and sex, and any other relevant characteristics. The dosages/sizes of all implant materials, spinal fusion rates, and follow-up time points were recorded. The data were analyzed and the results reported in tables and text. PRISMA guidelines were followed for this systematic review.

Cureus, 2019

Background Level 1 trauma centers are capable of caring for every aspect of injury and contain 24... more Background Level 1 trauma centers are capable of caring for every aspect of injury and contain 24-hour inhouse coverage by general surgeons, with prompt availability of nearly all other disciplines upon request. Despite the wide variety of trauma, currently reported protocols often focus on a single surgical service and studies describing their implementation are lacking. The aim of the current study was to characterize all urgent and emergent cases at a large academic Level 1 trauma center, characterize the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on timing of surgery. Methods For this retrospective review, all urgent and emergent cases treated at a single institution, during a 34-month period (January 1, 2015-October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Demographic characteristics for non-elective surgical emergent cases were compiled by level of urgency and operating room (OR) waiting times were compared by year, department, and Level. Results A total of 11,206 urgent and emergent operative cases were included, among over 16 surgical departments. Level 2 cases represented the majority of urgent/emergent cases (33%-36%), followed by Level 3 (25%-26%), Level 1 (21%-22%), Level 4 (12%-16%), and Level 5 (2%-4%). Univariate analysis demonstrated that the proportion of urgent and emergent cases, by level of urgency, did not significantly differ between each year. Operating room waiting time decreased

Neurosurgical focus, 2018

The Excelsius GPS (Globus Medical, Inc.) was approved by the FDA in 2017. This novel robot allows... more The Excelsius GPS (Globus Medical, Inc.) was approved by the FDA in 2017. This novel robot allows for real-time intraoperative imaging, registration, and direct screw insertion through a rigid external arm-without the need for interspinous clamps or K-wires. The authors present one of the first operative cases utilizing the Excelsius GPS robotic system in spinal surgery. A 75-year-old man presented with severe lower back pain and left leg radiculopathy. He had previously undergone 3 decompressive surgeries from L3 to L5, with evidence of instability and loss of sagittal balance. Robotic assistance was utilized to perform a revision decompression with instrumented fusion from L3 to S1. The usage of robotic assistance in spinal surgery may be an invaluable resource in minimally invasive cases, minimizing the need for fluoroscopy, or in those with abnormal anatomical landmarks. The video can be found here: https://youtu.be/yVI-sJWf9Iw .

Neurosurgical focus, 2018

In his 1920 science fiction play R.U.R., Czech writer Karel Capek introduced the word "robot... more In his 1920 science fiction play R.U.R., Czech writer Karel Capek introduced the word "robot" to the English language. The play tells the story of a factory that produces roboti, which are living creatures that resemble humans and have the capacity for individual thought. While at first the roboti seem content to work for their human masters, they later rebel, ultimately leading to the extinction of the human race. This play and similar depictions of robots in literature and film are probably responsible for the slightly negative reputation of robots in general. Only recently has this perception changed, thanks to the advent of robots that can vacuum our houses and perform other mundane chores. Raymond Goertz, while working for the US Atomic Energy Commission, is credited with the development of the first robotic arm in 1951. It was designed to handle hazardous radioactive material. Unimation Inc. developed the first industrial robot in 1961; that robot handled molten die-...

British journal of sports medicine, Jan 16, 2018

One of the National Football League's (NFL) Head, Neck and Spine Committee's principal go... more One of the National Football League's (NFL) Head, Neck and Spine Committee's principal goals is to create a 'best practice' protocol for concussion diagnosis and management for its players. The science related to concussion diagnosis and management continues to evolve, thus the protocol has evolved contemporaneously. The Fifth International Conference on Concussion in Sport was held in Berlin in 2016, and guidelines for sports concussion diagnosis and management were revised and refined. The NFL Head, Neck and Spine Committee has synthesised the most recent empirical evidence for sports concussion diagnosis and management including the Berlin consensus statement and tailored it to the game played in the NFL. One of the goals of the Committee is to provide a standardised, reliable, efficient and evidence-based protocol for concussion diagnosis and management that can be applied in this professional sport during practice and game day. In this article, the end-of-season...

Frontiers in Surgery, 2017

The open neuroimaging journal, 2016

Spinal cord injuries (SCI) are clinically challenging, because neural regeneration after cord dam... more Spinal cord injuries (SCI) are clinically challenging, because neural regeneration after cord damage is unknown. In SCI animal models, regeneration is evaluated histologically, requiring animal sacrifice. Noninvasive techniques are needed to detect longitudinal SCI changes. To compare manganese-enhanced magnetic resonance imaging (MRI [MEMRI]) in hemisection and transection of SCI rat models with diffusion tensor imaging (DTI) and histology. Rats underwent T9 spinal cord transection (n=6), hemisection (n=6), or laminectomy without SCI (controls, n=6). One-half of each group received lateral ventricle MnCl2 injections 24 hours later. Conventional DTI or T1-weighted MRI was performed 84 hours post-surgery. MEMRI signal intensity ratio above and below the SCI level was calculated. Fractional anisotropy (FA) measurements were taken 1 cm rostral to the SCI. The percentage of FA change was calculated 10 mm rostral to the SCI epicenter, between FA at the dorsal column lesion normalized to ...

World neurosurgery, Jan 21, 2016

Physical data are lacking on nutrient transport in human intervertebral discs (IVDs), which suppo... more Physical data are lacking on nutrient transport in human intervertebral discs (IVDs), which supports regeneration. Our objective was to study nutrient transport in porcine IVDs to determine the effects of biomechanical and physiological factors. In vitro testing of whole porcine IVDs was performed under different loading conditions. Fifty cervical, thoracic, and lumbar discs with attached end plates were removed from 4 Yorkshire pigs (90-150 pounds). Discs were placed in Safranin O or Fast Green FCF histological stains in diffusion or diurnal compression-tested groups. The end plate was studied by using polyurethane to block it. Traction was studied with a mechanical testing frame. Discs were cut transversely and photographed. Images were analyzed for depth of annulus fibrosus (AF) stained. The nucleus pulposus (NP) was assigned a staining score. Results showed no difference in AF staining between the two stains (P=0.60). The depth of AF staining did not increase (P=0.60) due to con...

SPINE, 2016

Tethered cord syndrome (TCS) occurs as a constellation of neurologic signs and symptoms resulting... more Tethered cord syndrome (TCS) occurs as a constellation of neurologic signs and symptoms resulting from longitudinal traction on the spinal cord between fixed points. This condition involves a tug-of-war between ascent and inhibition of ascent of intrathecal nervous tissue within the vertebral canal during growth. Causes include thickened filum terminale, myelomeningocele, split cord malformation, and previous intradural surgery. Patients report low back, lower extremity, and perineal pain; lower extremity sensory and motor deficits; urinary and bowel incontinence; and sexual dysfunction. When not treated early or adequately, TCS can lead to neurologic devastation.

Frontiers in Surgery, 2016

Background: Intervertebral disc degeneration (IVDD) is considered a multifactorial disease that i... more Background: Intervertebral disc degeneration (IVDD) is considered a multifactorial disease that is influenced by both environmental and genetic factors. The last two decades of research strongly demonstrate that genetic factors contribute about 75% of the IVDD etiology. Recent total genome sequencing studies have shed light on the various single-nucleotide polymorphisms (SNPs) that are associated with IVDD. Aim: This review presents comprehensive and updated information about the diversity of genetic factors in the inflammatory, degradative, homeostatic, and structural systems involved in the IVDD. An organized collection of information is provided regarding genetic polymorphisms that have been identified to influence the risk of developing IVDD. Understanding the proteins and signaling systems involved in IVDD can lead to improved understanding and targeting of therapeutics. Materials and methods: An electronic literature search was performed using the National Library of Medicine for publications using the keywords genetics of IVDD, lumbar disc degeneration, degenerative disc disease, polymorphisms, SNPs, and disc disease. The articles were then screened based on inclusion criteria that included topics that covered the correlation of SNPs with developing IVDD. Sixty-five articles were identified as containing relevant information. Articles were excluded if they investigated lower back pain or just disc herniation without an analysis of disc degeneration. This study focuses on the chronic degeneration of IVDs. Results: Various genes were identified to contain SNPs that influenced the risk of developing IVDD. Among these are genes contributing to structural proteins, such as COL1A1, COL9A3, COL9A3, COL11A1, and COL11A2, ACAN, and CHST3. Furthermore, various SNPs found in the vitamin-D receptor gene are also associated with IVDD. SNPs related to inflammatory cytokine imbalance are associated with IVDD, although some effects are limited by sex and certain populations. SNPs in genes that code for extracellular matrix-degrading enzymes, such as MMP-1, MMP-2, MMP-3, MMP-9, MMP-14,

World Neurosurgery, 2016

Although endoscopic diskectomy is superior to microsurgical diskectomy in terms of incision size,... more Although endoscopic diskectomy is superior to microsurgical diskectomy in terms of incision size, postoperative pain, and cosmetic appeal, the effectiveness and indications for endoscopic versus microsurgical diskectomy remain active discussion topics. Because of the increasing incidence of diskectomies being performed in Russia, further assessment of these techniques is needed. We performed a comparative analysis of 1-year clinical results and complications of microsurgical, tubular-based interlaminar endoscopic, and endoscopically assisted microsurgical diskectomies for patients with herniated lumbar disks.-METHODS: The patient cohort included 131 patients who were enrolled in a prospective, randomized controlled study and 617 patients for whom data were gathered retrospectively. The quality of life was assessed using the Oswestry Disability Index (version 2.1a) and pain severity was analyzed using the visual analog scale for pain preoperatively, at discharge, and at 3, 6, and 12 months postoperatively.-RESULTS: Microsurgical, tubular-based endoscopic, and endoscopically assisted microsurgical diskectomies were all effective in relieving acute radicular symptoms. Recurrent disk herniation occurred more frequently after tubular-based endoscopic diskectomy than after the other approaches.-CONCLUSIONS: Our findings indicate that these 3 surgical techniques are highly effective and have similar clinical results at 1-year follow-up. Although this study points to differences in complications resulting from the 3 techniques, larger prospective studies are needed to more definitively assess possible surgical differences, complications, and outcomes. The endoscopically assisted diskectomy technique allows for minimally invasive surgery and offers enhanced visualization of the anatomy that is hidden from view in microscopic procedures.

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Sep 15, 2016

It is important to realize that guidelines cannot always account for individual variation among p... more It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which event...

Journal of Neurosurgery: Spine

OBJECTIVE The authors systematically reviewed current evidence for the utility of mean arterial p... more OBJECTIVE The authors systematically reviewed current evidence for the utility of mean arterial pressure (MAP), intraspinal pressure (ISP), and spinal cord perfusion pressure (SCPP) as predictors of outcomes after traumatic spinal cord injury (SCI). METHODS PubMed, Cochrane Reviews Library, EMBASE, and Scopus databases were queried in December 2020. Two independent reviewers screened articles using Covidence software. Disagreements were resolved by a third reviewer. The inclusion criteria for articles were 1) available in English; 2) full text; 3) clinical studies on traumatic SCI interventions; 4) involved only human participants; and 5) focused on MAP, ISP, or SCPP. Exclusion criteria were 1) only available in non-English languages; 2) focused only on the brain; 3) described spinal diseases other than SCI; 4) interventions altering parameters other than MAP, ISP, or SCPP; and 5) animal studies. Studies were analyzed qualitatively and grouped into two categories: interventions incr...

Neurosurgical Focus

OBJECTIVE Damage to the thoracolumbar spine can confer significant morbidity and mortality. The T... more OBJECTIVE Damage to the thoracolumbar spine can confer significant morbidity and mortality. The Thoracolumbar Injury Classification and Severity Score (TLICS) is used to categorize injuries and determine patients at risk of spinal instability for whom surgical intervention is warranted. However, calculating this score can constitute a bottleneck in triaging and treating patients, as it relies on multiple imaging studies and a neurological examination. Therefore, the authors sought to develop and validate a deep learning model that can automatically categorize vertebral morphology and determine posterior ligamentous complex (PLC) integrity, two critical features of TLICS, using only CT scans. METHODS All patients who underwent neurosurgical consultation for traumatic spine injury or degenerative pathology resulting in spine injury at a single tertiary center from January 2018 to December 2019 were retrospectively evaluated for inclusion. The morphology of injury and integrity of the ...

Comparative effectiveness research has a vital role in recent health reform and policies. Special... more Comparative effectiveness research has a vital role in recent health reform and policies. Specialty training is one of these provider-side variables and surgeons who were trained in different specialties may have different outcomes upon performing the same procedure. The objective of this retrospective 1:1 propensity score-matched cohort study was to investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective posterior/transforaminal lumbar interbody fusion for degenerative spine diseases. 22,176 patients were reviewed from ACS-NSQIP database. Propensity score matching and subgroup analysis were utilized. After controlling for baseline characteristics in both groups (single/multi-level PLIF/TLIF), patients operated on by neurosurgeons were more likely to have longer operation time (239 vs 205 minutes / 276 vs 254 minutes), shorter total hospital stay (75 vs 96 hours / 85 vs 103 hours), lower return to ope...

arXiv: Medical Physics, 2020

Metal artifacts present a frequent challenge to cone-beam CT (CBCT) in image-guided surgery, obsc... more Metal artifacts present a frequent challenge to cone-beam CT (CBCT) in image-guided surgery, obscuring visualization of metal instruments and adjacent anatomy. Recent advances in mobile C-arm systems have enabled 3D imaging capacity with non-circular orbits. We extend a previously proposed metal artifacts avoidance (MAA) method to reduce the influence of metal artifacts by prospectively defining a non-circular orbit that avoids metal-induced biases in projection domain. Accurate geometric calibration is an important challenge to accurate 3D image reconstruction for such orbits. We investigate the performance of interpolation-based calibration from a library of circular orbits for any non-circular orbit. We apply the method to non-circular scans acquired for MAA, which involves: (i) coarse 3D localization of metal objects via only two scout views using an end-to-end trained neural network; (ii) calculation of the metal-induced x-ray spectral shift for all possible views; and (iii) id...

International Journal of Spine Surgery, 2021

Journal of Neurosurgery: Spine, 2021

OBJECTIVE Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in mult... more OBJECTIVE Enhanced Recovery After Surgery (ERAS) protocols have rapidly gained popularity in multiple surgical specialties and are recognized for their potential to improve patient outcomes and decrease hospitalization costs. However, they have only recently been applied to spinal surgery. The goal in the present work was to describe the development, implementation, and impact of an Enhanced Recovery After Spine Surgery (ERASS) protocol for patients undergoing elective spine procedures at an academic community hospital. METHODS A multidisciplinary team, drawing on prior publications and spine surgery best practices, collaborated to develop an ERASS protocol. Patients undergoing elective cervical or lumbar procedures were prospectively enrolled at a single tertiary care center; interventions were standardized across the cohort for pre-, intra-, and postoperative care using standardized order sets in the electronic medical record. Protocol efficacy was evaluated by comparing enrolled ...

Journal of Neurosurgery: Spine, 2021

OBJECTIVE Although fellowship training is becoming increasingly common in neurosurgery, it is unc... more OBJECTIVE Although fellowship training is becoming increasingly common in neurosurgery, it is unclear which factors predict an academic career trajectory among spinal neurosurgeons. In this study, the authors sought to identify predictors associated with academic career placement among fellowship-trained neurological spinal surgeons. METHODS Demographic data and bibliometric information on neurosurgeons who completed a residency program accredited by the Accreditation Council for Graduate Medical Education between 1983 and 2019 were gathered, and those who completed a spine fellowship were identified. Employment was denoted as academic if the hospital where a neurosurgeon worked was affiliated with a neurosurgical residency program; all other positions were denoted as nonacademic. A logistic regression model was used for multivariate statistical analysis. RESULTS A total of 376 fellowship-trained spinal neurosurgeons were identified, of whom 140 (37.2%) held academic positions. The ...

Operative Neurosurgery, 2021

The increasing interest and advancements in robotic spine surgery parallels a growing emphasis on... more The increasing interest and advancements in robotic spine surgery parallels a growing emphasis on maximizing patient safety and outcomes. In addition, an increasing interest in minimally invasive spine surgery has further fueled robotic development, as robotic guidance systems are aptly suited for these procedures. This review aims to address 3 of the most critical aspects of robotics in spine surgery today: salient details regarding the current and future development of robotic systems and functionalities, the reported accuracy of implant placement over the years, and how the implementation of robotic systems will impact the training of future generations of spine surgeons. As current systems establish themselves as highly accurate tools for implant placement, the development of novel features, including even robotic-assisted decompression, will likely occur. As spine surgery robots evolve and become increasingly adopted, it is likely that resident and fellow education will follow ...

World Journal of Orthopedics, 2019

BACKGROUND Over 400000 Americans annually undergo spinal fusion surgeries, yet up to 40% of these... more BACKGROUND Over 400000 Americans annually undergo spinal fusion surgeries, yet up to 40% of these procedures result in pseudoarthrosis even with iliac crest autograft, the current "gold standard" treatment. Tissue engineering has the potential to solve this problem via the creation of bone grafts involving bone-promoting growth factors (e.g., bone morphogenetic protein 2). A broad assessment of experimental growth factors is important to inform future work and clinical potential in this area. To date, however, no study has systematically reviewed the investigational growth factors utilized in preclinical animal models of spinal fusion. AIM To review all published studies assessing investigational growth factors for spinal fusion in animal models and identify promising agents for translation. METHODS We conducted a systematic review of the literature using PubMed, Embase, Cochrane Library, and Web of Science databases with searches run on May 29 th , 2018. The search query was designed to include all non-human, preclinical animal models of spinal fusion reported in the literature without a timespan limit. Extracted data for each model included surgical approach, level of fusion, animal species and breed, animal age and sex, and any other relevant characteristics. The dosages/sizes of all implant materials, spinal fusion rates, and follow-up time points were recorded. The data were analyzed and the results reported in tables and text. PRISMA guidelines were followed for this systematic review.

Cureus, 2019

Background Level 1 trauma centers are capable of caring for every aspect of injury and contain 24... more Background Level 1 trauma centers are capable of caring for every aspect of injury and contain 24-hour inhouse coverage by general surgeons, with prompt availability of nearly all other disciplines upon request. Despite the wide variety of trauma, currently reported protocols often focus on a single surgical service and studies describing their implementation are lacking. The aim of the current study was to characterize all urgent and emergent cases at a large academic Level 1 trauma center, characterize the specialty and nature of emergent operative cases, and assess the efficacy of the institutional trauma protocol on timing of surgery. Methods For this retrospective review, all urgent and emergent cases treated at a single institution, during a 34-month period (January 1, 2015-October 31, 2017), were identified. All included cases were subject to the Institutional Guidelines for Operative Urgent/Emergent Cases. Demographic characteristics for non-elective surgical emergent cases were compiled by level of urgency and operating room (OR) waiting times were compared by year, department, and Level. Results A total of 11,206 urgent and emergent operative cases were included, among over 16 surgical departments. Level 2 cases represented the majority of urgent/emergent cases (33%-36%), followed by Level 3 (25%-26%), Level 1 (21%-22%), Level 4 (12%-16%), and Level 5 (2%-4%). Univariate analysis demonstrated that the proportion of urgent and emergent cases, by level of urgency, did not significantly differ between each year. Operating room waiting time decreased

Neurosurgical focus, 2018

The Excelsius GPS (Globus Medical, Inc.) was approved by the FDA in 2017. This novel robot allows... more The Excelsius GPS (Globus Medical, Inc.) was approved by the FDA in 2017. This novel robot allows for real-time intraoperative imaging, registration, and direct screw insertion through a rigid external arm-without the need for interspinous clamps or K-wires. The authors present one of the first operative cases utilizing the Excelsius GPS robotic system in spinal surgery. A 75-year-old man presented with severe lower back pain and left leg radiculopathy. He had previously undergone 3 decompressive surgeries from L3 to L5, with evidence of instability and loss of sagittal balance. Robotic assistance was utilized to perform a revision decompression with instrumented fusion from L3 to S1. The usage of robotic assistance in spinal surgery may be an invaluable resource in minimally invasive cases, minimizing the need for fluoroscopy, or in those with abnormal anatomical landmarks. The video can be found here: https://youtu.be/yVI-sJWf9Iw .

Neurosurgical focus, 2018

In his 1920 science fiction play R.U.R., Czech writer Karel Capek introduced the word "robot... more In his 1920 science fiction play R.U.R., Czech writer Karel Capek introduced the word "robot" to the English language. The play tells the story of a factory that produces roboti, which are living creatures that resemble humans and have the capacity for individual thought. While at first the roboti seem content to work for their human masters, they later rebel, ultimately leading to the extinction of the human race. This play and similar depictions of robots in literature and film are probably responsible for the slightly negative reputation of robots in general. Only recently has this perception changed, thanks to the advent of robots that can vacuum our houses and perform other mundane chores. Raymond Goertz, while working for the US Atomic Energy Commission, is credited with the development of the first robotic arm in 1951. It was designed to handle hazardous radioactive material. Unimation Inc. developed the first industrial robot in 1961; that robot handled molten die-...

British journal of sports medicine, Jan 16, 2018

One of the National Football League's (NFL) Head, Neck and Spine Committee's principal go... more One of the National Football League's (NFL) Head, Neck and Spine Committee's principal goals is to create a 'best practice' protocol for concussion diagnosis and management for its players. The science related to concussion diagnosis and management continues to evolve, thus the protocol has evolved contemporaneously. The Fifth International Conference on Concussion in Sport was held in Berlin in 2016, and guidelines for sports concussion diagnosis and management were revised and refined. The NFL Head, Neck and Spine Committee has synthesised the most recent empirical evidence for sports concussion diagnosis and management including the Berlin consensus statement and tailored it to the game played in the NFL. One of the goals of the Committee is to provide a standardised, reliable, efficient and evidence-based protocol for concussion diagnosis and management that can be applied in this professional sport during practice and game day. In this article, the end-of-season...

Frontiers in Surgery, 2017

The open neuroimaging journal, 2016

Spinal cord injuries (SCI) are clinically challenging, because neural regeneration after cord dam... more Spinal cord injuries (SCI) are clinically challenging, because neural regeneration after cord damage is unknown. In SCI animal models, regeneration is evaluated histologically, requiring animal sacrifice. Noninvasive techniques are needed to detect longitudinal SCI changes. To compare manganese-enhanced magnetic resonance imaging (MRI [MEMRI]) in hemisection and transection of SCI rat models with diffusion tensor imaging (DTI) and histology. Rats underwent T9 spinal cord transection (n=6), hemisection (n=6), or laminectomy without SCI (controls, n=6). One-half of each group received lateral ventricle MnCl2 injections 24 hours later. Conventional DTI or T1-weighted MRI was performed 84 hours post-surgery. MEMRI signal intensity ratio above and below the SCI level was calculated. Fractional anisotropy (FA) measurements were taken 1 cm rostral to the SCI. The percentage of FA change was calculated 10 mm rostral to the SCI epicenter, between FA at the dorsal column lesion normalized to ...

World neurosurgery, Jan 21, 2016

Physical data are lacking on nutrient transport in human intervertebral discs (IVDs), which suppo... more Physical data are lacking on nutrient transport in human intervertebral discs (IVDs), which supports regeneration. Our objective was to study nutrient transport in porcine IVDs to determine the effects of biomechanical and physiological factors. In vitro testing of whole porcine IVDs was performed under different loading conditions. Fifty cervical, thoracic, and lumbar discs with attached end plates were removed from 4 Yorkshire pigs (90-150 pounds). Discs were placed in Safranin O or Fast Green FCF histological stains in diffusion or diurnal compression-tested groups. The end plate was studied by using polyurethane to block it. Traction was studied with a mechanical testing frame. Discs were cut transversely and photographed. Images were analyzed for depth of annulus fibrosus (AF) stained. The nucleus pulposus (NP) was assigned a staining score. Results showed no difference in AF staining between the two stains (P=0.60). The depth of AF staining did not increase (P=0.60) due to con...

SPINE, 2016

Tethered cord syndrome (TCS) occurs as a constellation of neurologic signs and symptoms resulting... more Tethered cord syndrome (TCS) occurs as a constellation of neurologic signs and symptoms resulting from longitudinal traction on the spinal cord between fixed points. This condition involves a tug-of-war between ascent and inhibition of ascent of intrathecal nervous tissue within the vertebral canal during growth. Causes include thickened filum terminale, myelomeningocele, split cord malformation, and previous intradural surgery. Patients report low back, lower extremity, and perineal pain; lower extremity sensory and motor deficits; urinary and bowel incontinence; and sexual dysfunction. When not treated early or adequately, TCS can lead to neurologic devastation.

Frontiers in Surgery, 2016

Background: Intervertebral disc degeneration (IVDD) is considered a multifactorial disease that i... more Background: Intervertebral disc degeneration (IVDD) is considered a multifactorial disease that is influenced by both environmental and genetic factors. The last two decades of research strongly demonstrate that genetic factors contribute about 75% of the IVDD etiology. Recent total genome sequencing studies have shed light on the various single-nucleotide polymorphisms (SNPs) that are associated with IVDD. Aim: This review presents comprehensive and updated information about the diversity of genetic factors in the inflammatory, degradative, homeostatic, and structural systems involved in the IVDD. An organized collection of information is provided regarding genetic polymorphisms that have been identified to influence the risk of developing IVDD. Understanding the proteins and signaling systems involved in IVDD can lead to improved understanding and targeting of therapeutics. Materials and methods: An electronic literature search was performed using the National Library of Medicine for publications using the keywords genetics of IVDD, lumbar disc degeneration, degenerative disc disease, polymorphisms, SNPs, and disc disease. The articles were then screened based on inclusion criteria that included topics that covered the correlation of SNPs with developing IVDD. Sixty-five articles were identified as containing relevant information. Articles were excluded if they investigated lower back pain or just disc herniation without an analysis of disc degeneration. This study focuses on the chronic degeneration of IVDs. Results: Various genes were identified to contain SNPs that influenced the risk of developing IVDD. Among these are genes contributing to structural proteins, such as COL1A1, COL9A3, COL9A3, COL11A1, and COL11A2, ACAN, and CHST3. Furthermore, various SNPs found in the vitamin-D receptor gene are also associated with IVDD. SNPs related to inflammatory cytokine imbalance are associated with IVDD, although some effects are limited by sex and certain populations. SNPs in genes that code for extracellular matrix-degrading enzymes, such as MMP-1, MMP-2, MMP-3, MMP-9, MMP-14,

World Neurosurgery, 2016

Although endoscopic diskectomy is superior to microsurgical diskectomy in terms of incision size,... more Although endoscopic diskectomy is superior to microsurgical diskectomy in terms of incision size, postoperative pain, and cosmetic appeal, the effectiveness and indications for endoscopic versus microsurgical diskectomy remain active discussion topics. Because of the increasing incidence of diskectomies being performed in Russia, further assessment of these techniques is needed. We performed a comparative analysis of 1-year clinical results and complications of microsurgical, tubular-based interlaminar endoscopic, and endoscopically assisted microsurgical diskectomies for patients with herniated lumbar disks.-METHODS: The patient cohort included 131 patients who were enrolled in a prospective, randomized controlled study and 617 patients for whom data were gathered retrospectively. The quality of life was assessed using the Oswestry Disability Index (version 2.1a) and pain severity was analyzed using the visual analog scale for pain preoperatively, at discharge, and at 3, 6, and 12 months postoperatively.-RESULTS: Microsurgical, tubular-based endoscopic, and endoscopically assisted microsurgical diskectomies were all effective in relieving acute radicular symptoms. Recurrent disk herniation occurred more frequently after tubular-based endoscopic diskectomy than after the other approaches.-CONCLUSIONS: Our findings indicate that these 3 surgical techniques are highly effective and have similar clinical results at 1-year follow-up. Although this study points to differences in complications resulting from the 3 techniques, larger prospective studies are needed to more definitively assess possible surgical differences, complications, and outcomes. The endoscopically assisted diskectomy technique allows for minimally invasive surgery and offers enhanced visualization of the anatomy that is hidden from view in microscopic procedures.

Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, Sep 15, 2016

It is important to realize that guidelines cannot always account for individual variation among p... more It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. Infectious Diseases Society of America considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.Coccidioidomycosis, also known as San Joaquin Valley fever, is a systemic infection endemic to parts of the southwestern United States and elsewhere in the Western Hemisphere. Residence in and recent travel to these areas are critical elements for the accurate recognition of patients who develop this infection. In this practice guideline, we have organized our recommendations to address actionable questions concerning the entire spectrum of clinical syndromes. These can range from initial pulmonary infection, which event...