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Open Access
Challenges to Improving Palliative Care and the Role of an Anesthesiologist
(ASA Monitor, 2024-11-01) Karnati, Rohit; Yi, Peter; Anwar, Muhammad A Farooq
Open Access
Comparing the Incidence of Index Level Fusion Following Minimally Invasive Versus Open Lumbar Microdiscectomy
(Global Spine Journal, 2018-02-01) McAnany, SJ; Overley, SC; Anwar, MA; Cutler, HS; Guzman, JZ; Kim, JS; Merrill, RK; Cho, SK; Hecht, AC; Qureshi, SA
Study Design: Retrospective cohort study. Objectives: To determine the incidence of index level fusion following open or minimally invasive lumbar microdiscectomy. Methods: We conducted a retrospective review of 174 patients with a symptomatic single-level lumbar herniated nucleus pulposus who underwent microdiscectomy via a mini-open approach (MIS; 39) or through a minimally invasive dilator tube (135). Outcomes of interest included revision microdiscectomy and the ultimate need for index level fusion. Continuous variables were analyzed with independent sample t test, and χ2 analysis was used for categorical data. A multivariate regression analysis was performed to identify predictive factors for patients that required index level fusion after lumbar microdiscectomy. Results: There was no difference in patient demographics in the open and MIS groups aside from length of follow-up (60.4 vs 40.03 months, P <.0001) and body mass index (24.72 vs 27.21, P =.03). The rate of revision microdiscectomy was not statistically significant between open and MIS approaches (10.3% vs 10.4%, P =.90). The rate of patients who ultimately required index level fusion approached significance, but was not statistically different between open and MIS approaches (10.3% vs 4.4%, P =.17). Multivariate regression analysis indicated that the need for eventual index level fusion after lumbar microdiscectomy was statistically predicted in smokers and those patients who underwent revision microdiscectomy (P <.05) in both open and MIS groups. Conclusions: Our results suggest a low likelihood of patients ultimately requiring fusion following microdiscectomy with predictors including smoking status and a history of revision microdiscectomy.
Open Access
Decision analytic modeling in spinal surgery: a methodologic overview with review of current published literature.
(The spine journal : official journal of the North American Spine Society, 2015-10) McAnany, Steven J; Anwar, Muhammad AF; Qureshi, Sheeraz A
Background context
In recent years, there has been an increase in the number of decision analysis studies in the spine literature. Although there are several published reviews on the different types of decision analysis (cost-effectiveness, cost-benefit, cost-utility), there is limited information in the spine literature regarding the mathematical models used in these studies (decision tree, Markov modeling, Monte Carlo simulation).
Purpose
The purpose of this review was to provide an overview of the types of decision analytic models used in spine surgery. A secondary aim was to provide a systematic overview of the most cited studies in the spine literature.
Study design/setting
This is a systematic review of the available information from all sources regarding decision analytics and economic modeling in spine surgery.
Methods
A systematic search of PubMed, Embase, and Cochrane review was performed to identify the most relevant peer-reviewed literature of decision analysis/cost-effectiveness analysis (CEA) models including decisions trees, Markov models, and Monte Carlo simulations. Additionally, CEA models based on investigational drug exemption studies were reviewed in particular detail, as these studies are prime candidates for economic modeling.
Results
The initial review of the literature resulted in 712 abstracts. After two reviewer-assessment of abstract relevance and methodologic quality, 19 studies were selected: 12 with decision tree constructs and 7 with Markov models. Each study was assessed for methodologic quality and a review of the overall results of the model. A generalized overview of the mathematical construction and methodology of each type of model was also performed. Limitations, strengths, and potential applications to spine research were further explored.
Conclusions
Decision analytic modeling represents a powerful tool both in the assessment of competing treatment options and potentially in the formulation of policy and reimbursement. Our review provides a generalized overview and a conceptual framework to help spine physicians with the construction of these models.
Open Access
Electrical neuromodulation – past, present, and future directions
(ASRA News, 2022-08-01) Due, Bradley; Farooq Anwar, Muhammad; Vorenkamp, Kevin
Open Access
Ensuring Access to Pain Care
(ASA Monitor, 2024-06-01) Anwar, Muhammad A Farooq; Doan, Lisa V; Noon, Kristen
Open Access
Genetic variant rs3750625 in the 3'UTR of ADRA2A affects stress-dependent acute pain severity after trauma and alters a microRNA-34a regulatory site.
(Pain, 2017-02) Linnstaedt, Sarah D; Walker, Margaret G; Riker, Kyle D; Nyland, Jennifer E; Hu, JunMei; Rossi, Catherine; Swor, Robert A; Jones, Jeffrey S; Diatchenko, Luda; Bortsov, Andrey V; Peak, David A; McLean, Samuel A
α2A adrenergic receptor (α2A-AR) activation has been shown in animal models to play an important role in regulating the balance of acute pain inhibition vs facilitation after both physical and psychological stress. To our knowledge, the influence of genetic variants in the gene encoding α2A-AR, ADRA2A, on acute pain outcomes in humans experiencing traumatic stress has not been assessed. In this study, we tested whether a genetic variant in the 3'UTR of ADRA2A, rs3750625, is associated with acute musculoskeletal pain (MSP) severity following motor vehicle collision (MVC, n = 948) and sexual assault (n = 84), and whether this influence was affected by stress severity. We evaluated rs3750625 because it is located in the seed binding region of miR-34a, a microRNA (miRNA) known to regulate pain and stress responses. In both cohorts, the minor allele at rs3750625 was associated with increased musculoskeletal pain in distressed individuals (stress*rs3750625 P = 0.043 for MVC cohort and P = 0.007 for sexual assault cohort). We further found that (1) miR-34a binds the 3'UTR of ADRA2A, (2) the amount of repression is greater when the minor (risk) allele is present, (3) miR-34a in the IMR-32 adrenergic neuroblastoma cell line affects ADRA2A expression, (4) miR-34a and ADRA2A are expressed in tissues known to play a role in pain and stress, (5) following forced swim stress exposure, rat peripheral nerve tissue expression changes are consistent with miR-34a regulation of ADRA2A. Together, these results suggest that ADRA2A rs3750625 contributes to poststress musculoskeletal pain severity by modulating miR-34a regulation.
Open Access
Immunomodulatory lipid mediator profiling of cerebrospinal fluid following surgery in older adults.
(Scientific reports, 2021-02-04) Terrando, Niccolò; Park, John J; Devinney, Michael; Chan, Cliburn; Cooter, Mary; Avasarala, Pallavi; Mathew, Joseph P; Quinones, Quintin J; Maddipati, Krishna Rao; Berger, Miles; MADCO-PC Study Team
Arachidonic acid (AA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA) derived lipids play key roles in initiating and resolving inflammation. Neuro-inflammation is thought to play a causal role in perioperative neurocognitive disorders, yet the role of these lipids in the human central nervous system in such disorders is unclear. Here we used liquid chromatography-mass spectrometry to quantify AA, DHA, and EPA derived lipid levels in non-centrifuged cerebrospinal fluid (CSF), centrifuged CSF pellets, and centrifuged CSF supernatants of older adults obtained before, 24 h and 6 weeks after surgery. GAGE analysis was used to determine AA, DHA and EPA metabolite pathway changes over time. Lipid mediators derived from AA, DHA and EPA were detected in all sample types. Postoperative lipid mediator changes were not significant in non-centrifuged CSF (p > 0.05 for all three pathways). The AA metabolite pathway showed significant changes in centrifuged CSF pellets and supernatants from before to 24 h after surgery (p = 0.0000247, p = 0.0155 respectively), from before to 6 weeks after surgery (p = 0.0000497, p = 0.0155, respectively), and from 24 h to 6 weeks after surgery (p = 0.0000499, p = 0.00363, respectively). These findings indicate that AA, DHA, and EPA derived lipids are detectable in human CSF, and the AA metabolite pathway shows postoperative changes in centrifuged CSF pellets and supernatants.
Open Access
Opioid Induced Hyperalgesia
(Pain) Yi, Peter
Open Access
Phenotypic profile clustering pragmatically identifies diagnostically and mechanistically informative subgroups of chronic pain patients.
(Pain, 2021-05) Gaynor, Sheila M; Bortsov, Andrey; Bair, Eric; Fillingim, Roger B; Greenspan, Joel D; Ohrbach, Richard; Diatchenko, Luda; Nackley, Andrea; Tchivileva, Inna E; Whitehead, William; Alonso, Aurelio A; Buchheit, Thomas E; Boortz-Marx, Richard L; Liedtke, Wolfgang; Park, Jongbae J; Maixner, William; Smith, Shad B
Abstract
Traditional classification and prognostic approaches for chronic pain conditions focus primarily on anatomically based clinical characteristics not based on underlying biopsychosocial factors contributing to perception of clinical pain and future pain trajectories. Using a supervised clustering approach in a cohort of temporomandibular disorder cases and controls from the Orofacial Pain: Prospective Evaluation and Risk Assessment study, we recently developed and validated a rapid algorithm (ROPA) to pragmatically classify chronic pain patients into 3 groups that differed in clinical pain report, biopsychosocial profiles, functional limitations, and comorbid conditions. The present aim was to examine the generalizability of this clustering procedure in 2 additional cohorts: a cohort of patients with chronic overlapping pain conditions (Complex Persistent Pain Conditions study) and a real-world clinical population of patients seeking treatment at duke innovative pain therapies. In each cohort, we applied a ROPA for cluster prediction, which requires only 4 input variables: pressure pain threshold and anxiety, depression, and somatization scales. In both complex persistent pain condition and duke innovative pain therapies, we distinguished 3 clusters, including one with more severe clinical characteristics and psychological distress. We observed strong concordance with observed cluster solutions, indicating the ROPA method allows for reliable subtyping of clinical populations with minimal patient burden. The ROPA clustering algorithm represents a rapid and valid stratification tool independent of anatomic diagnosis. ROPA holds promise in classifying patients based on pathophysiological mechanisms rather than structural or anatomical diagnoses. As such, this method of classifying patients will facilitate personalized pain medicine for patients with chronic pain.
Open Access
Postoperative changes in cognition and cerebrospinal fluid neurodegenerative disease biomarkers.
(Annals of clinical and translational neurology, 2022-02) Berger, Miles; Browndyke, Jeffrey N; Cooter Wright, Mary; Nobuhara, Chloe; Reese, Melody; Acker, Leah; Bullock, W Michael; Colin, Brian J; Devinney, Michael J; Moretti, Eugene W; Moul, Judd W; Ohlendorf, Brian; Laskowitz, Daniel T; Waligorska, Teresa; Shaw, Leslie M; Whitson, Heather E; Cohen, Harvey J; Mathew, Joseph P; MADCO-PC Investigators
Objective
Numerous investigators have theorized that postoperative changes in Alzheimer's disease neuropathology may underlie postoperative neurocognitive disorders. Thus, we determined the relationship between postoperative changes in cognition and cerebrospinal (CSF) tau, p-tau-181p, or Aβ levels after non-cardiac, non-neurologic surgery in older adults.
Methods
Participants underwent cognitive testing before and 6 weeks after surgery, and lumbar punctures before, 24 h after, and 6 weeks after surgery. Cognitive scores were combined via factor analysis into an overall cognitive index. In total, 110 patients returned for 6-week postoperative testing and were included in the analysis.
Results
There was no significant change from before to 24 h or 6 weeks following surgery in CSF tau (median [median absolute deviation] change before to 24 h: 0.00 [4.36] pg/mL, p = 0.853; change before to 6 weeks: -1.21 [3.98] pg/mL, p = 0.827). There were also no significant changes in CSF p-tau-181p or Aβ over this period. There was no change in cognitive index (mean [95% CI] 0.040 [-0.018, 0.098], p = 0.175) from before to 6 weeks after surgery, although there were postoperative declines in verbal memory (-0.346 [-0.523, -0.170], p = 0.003) and improvements in executive function (0.394, [0.310, 0.479], p < 0.001). There were no significant correlations between preoperative to 6-week postoperative changes in cognition and CSF tau, p-tau-181p, or Aβ42 changes over this interval (p > 0.05 for each).
Interpretation
Neurocognitive changes after non-cardiac, non-neurologic surgery in the majority of cognitively healthy, community-dwelling older adults are unlikely to be related to postoperative changes in AD neuropathology (as assessed by CSF Aβ, tau or p-tau-181p levels or the p-tau-181p/Aβ or tau/Aβ ratios).
Trial registration
clinicaltrials.gov (NCT01993836).
Open Access
Predictive factors and rates of fusion in minimally invasive transforaminal lumbar interbody fusion utilizing rhBMP-2 or mesenchymal stem cells
(International Journal of Spine Surgery, 2019-01-01) Overley, SC; McAnany, SJ; Anwar, MA; Merrill, RK; Lovy, A; Guzman, JZ; Zhadanov, S; Doshi, A; Rothenberg, E; Vaishnav, A; Gang, C; Qureshi, SA
Background: Several fusion adjuncts exist to enhance fusion rates during minimally invasive transforaminal lumbar interbody fusion (MI-TLIF). The objective of this study was to compare fusion rates in patients undergoing MI-TLIF with either rhBMP-2 or cellularized bone matrix (CBM). Methods: We conducted a single surgeon retrospective cohort study of patients who underwent MI-TLIF with either rhBMP-2 or CBM placed in an interbody cage. Single and multilevel procedures were included. Fusion was assessed on computed tomography scans at 12-month follow-up by an independent, blinded, board-certified neuroradiologist. Fusion rates and rate of revision surgery were compared with a Fisher exact test between the 2 groups. A multivariate regression analysis was performed to identify patient factors that were predictive of radiographic nonunion after MI-TLIF. Results: A total of 93 fusion levels in 78 patients were reviewed. Thirty-nine patients received CBM, and 39 patients received rhBMP-2. The patients receiving rhBMP-2 were older on average (61.4 vs 55.6, P = .03). The overall fusion rate was 68% in the CBM group (32/47 levels) and 78% in the rhBMP-2 group (36/46) (P = .35). Only preoperative hypertension was predictive of radiographic nonunion (odds ratio = 3.5, P = .05). There were 3 smokers in the CBM group and 4 smokers in the BMP group, and 1 in each group experienced radiographic pseudarthrosis. A total of 4 patients, 3 in the CBM group and 1 in the BMP group (P = .61), required revision for symptomatic pseudarthrosis. All of these patients had a single-level index procedure. Conclusions: There were no differences in radiographic fusion and rate of revision surgery in patients who underwent MI-TLIF with either rhBMP-2 or CBM as fusion adjuncts. Level of Evidence: 3 Clinical Relevance: Both rhBMP-2 and CBMs can be used as effective fusion adjuncts without any clear advantage of one over the other.
Open Access
Self-system therapy for distress associated with persistent low back pain: A randomized clinical trial.
(Psychother Res, 2016-07) Waters, Sandra J; Strauman, Timothy J; McKee, Daphne C; Campbell, Lisa C; Shelby, Rebecca A; Dixon, Kim E; Fras, Anne Marie; Keefe, Francis J
OBJECTIVE: Persistent low back pain (PLBP) is associated with vulnerability to depression. PLBP frequently requires major changes in occupation and lifestyle, which can lead to a sense of failing to attain one's personal goals (self-discrepancy). METHOD: We conducted a clinical trial to examine the efficacy of self-system therapy (SST), a brief structured therapy for depression based on self-discrepancy theory. A total of 101 patients with PLBP and clinically significant depressive symptoms were randomized either to SST, pain education, or standard care. RESULTS: Patients receiving SST showed significantly greater improvement in depressive symptoms. Reduction in self-discrepancy predicted reduction in depressive symptoms only within the SST condition. CONCLUSIONS: Findings support the utility of SST for individuals facing persistent pain and associated depression.