Browsing by Author "Foster, Norah"
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Item Open Access Comparison of intraoperative and postoperative outcomes between open, wiltse, and percutaneous approach to traumatic thoracolumbar spine fractures without neurological injury: A systematic review and meta-analysis.(North American Spine Society journal, 2024-12) Al-Naseem, Abdulrahman O; Mehkri, Yusuf; Chakravarti, Sachiv; Johnson, Eli; Kelly-Hedrick, Margot; Kuo, Cathleen; Erickson, Melissa; Than, Khoi D; Rocos, Brett; Bhowmick, Deb; Shaffrey, Christopher I; Foster, Norah; Baaj, Ali; Dahdaleh, Nader; Goodwin, C Rory; Williamson, Theresa L; Lu, Yi; Abd-El-Barr, Muhammad MBackground
Traumatic thoracolumbar fracture fixation without neurological injury can be performed using the traditional open, mini-open Wiltse, and percutaneous approaches. This systematic review and meta-analysis aims to compare perioperative outcomes between these approaches.Methods
PubMed, Web of Science, Scopus, Embase, and the Cochrane Library were searched for all relevant observational comparative studies.Results
5 randomized trials and 22 comparative cohort studies were included. Compared to the traditional open approach (n=959), the Wiltse approach (n=410) was associated with significantly lower operative time, intraoperative estimated blood loss (EBL), and length of stay (LOS). There was no significant difference between the two in terms of postoperative visual analog scale (VAS) and Cobb angle. Compared to the percutaneous approach (n=980), the Wiltse approach was associated with shorter operative and fluoroscopy time, as well as significantly improved Cobb and vertebral body angles. The percutaneous approach was associated with improved vertebral body height. There was no significant difference between the two for blood loss, postoperative VAS, or LOS. Compared to the traditional open approach, the percutaneous approach was associated with shorter operative time, lower EBL, shorter LOS and better postoperative VAS and Oswestry Disability Index. There was no difference between the two in postoperative Cobb angle, vertebral angle, or vertebral body height. Overall study heterogeneity was high.Conclusions
Utilization of minimally invasive surgical approaches holds great promise for lowering patient morbidity and optimizing care. A prospective trial is needed to assess outcomes and guide surgical decision making.Item Open Access Demographics, Mechanism of Injury and Outcomes for Acute Upper and Lower Cervical Spinal Cord Injuries - An Analysis of 470 Patients in the Prospective, Multicenter North American Clinical Trials Network (NACTN) Registry.(Journal of neurotrauma, 2023-02) Futch, Brittany Grace; Kouam, Romaric Waguia; Ugiliweneza, Beatrice; Harrop, James; Kurpad, Shekar; Foster, Norah; Than, Khoi; Crutcher, Clifford; Goodwin, C Rory; Tator, Charles; Shaffrey, Christopher I; Aarabi, Bizhan; Fehlings, Michael; Neal, Chris J; Guest, James; Abd-El-Barr, Muhammad MThere is a paucity of data comparing the demographics, mechanism of injury, and outcomes of upper versus lower cervical spinal cord injuries (cSCI). The study objective was to define different clinical manifestations of cSCI. Data were collected prospectively through centers of the North American Clinical Trials Network (NACTN). Data was collected on 470 patients (21% women, mean age 50 years). Cervical vertebral level was analyzed as an ordinal variable to determine a natural demarcation to classify upper versus lower cSCI. For continuous variable analysis, falls were associated with C3 more than C4 vertebral level injuries (60% vs. 42%) (p=0.0126), while motor vehicle accidents (MVA) were associated with C4 more than C3 (40% vs. 29%) (p=0.0962). Motor ISNSCI scores also demonstrated a natural demarcation between C3 and C4, with C3 having higher median ASIA motor scores (40 [4 - 73] vs. 11 [3 - 59], p= 0.0227). There were no differences when comparing C2 to C3 nor C4 to C5. Given the significant differences seen between C3 and C4, but not C2 and C3 nor C4 and C5, upper cSCI was designated as C1-C3, and lower cSCI was designated as C4-C7. Compared to a lower cSCI, patients with an upper cSCI were more likely to have a fall as their mechanism of injury (54% vs. 36%, p= 0.0072). Patients with an ASIA C cSCI were likely to have an upper cervical injury: 23% vs. 11% (p= 0.0226). Additionally, patients with an upper cSCI were more likely to have diabetes prior to injury, 37% vs. 22% respectively (p= 0.0084). Lower cSCI were more likely injured through sports (19% vs. 8%, p= 0.0171) and present with ASIA A (42% vs. 25%, p= 0.0186) neurological grade. Patients with lower cSCI were also significantly more likely to have complications such as shock, pulmonary embolism, and pleural effusion. In conclusion, there appears to be a natural demarcation of injury type between C3 and C4. Upper cSCI (C1-C3) was more associated with falls and diabetes, whereas lower cSCI (C4-C7) was more associated with sports, worse ASIA scores, and more complications. Further research will be needed to understand the mechanistic and biological differences between these two groups and whether different treatments may be appropriate for each of these groups.Item Open Access Image Quality and Dose Comparison of 3 Mobile Intraoperative Three-Dimensional Imaging Systems in Spine Surgery.(World neurosurgery, 2022-04) Foster, Norah; Shaffrey, Christopher; Buchholz, Avery; Turner, Raymond; Yang, Lexie Zidanyue; Niedzwiecki, Donna; Goode, AllenObjective
To evaluate radiation exposure and image quality (IQ) for 3 intraoperative imaging systems (Airo TruCT, Cios Spin, O-arm) using varying radiation dose settings in a single cadaveric model.Methods
Axial images of L4-5 instrumentation were obtained using 3 manufacturer dose protocols for each system. Measurements included scattered radiation dose, subjective and objective IQ, and estimates of patient effective dose (ED). Four images per system were selected at each dose level. Using the Likert scale (1 = best, 5 = worst), 9 reviewers rated the same 36 images. Objective IQ measures included the degree of streak artifacts (lines with incorrect data from metal objects) in each image. A composite figure of merit was derived based on ED and subjective and objective scores.Results
The best subjective IQ scores were 1.44 (Cios Spin medium dose), 1.78 (Cios Spin high dose) and 2.22 (Airo TruCT low dose). The best objective IQ scores were 87.3 (Airo TruCT) and 89.1 (Cios Spin). ED low-dose results in mSv included 1.6 (Airo TruCT), 1.9 (Cios Spin), and 3.3 (O-arm). ED high-dose results in mSv included 4.6 (Cios Spin), 9.7 (Airo TruCT), and 9.9 (O-arm). Scatter radiation measurements for low dose in μGy included 21.9 (Cios Spin), 31.8 (Airo TruCT), and 33.9 (O-arm). Scatter radiation for high dose in μGy included 55.9 (Cios Spin), 104.5 (O-arm), and 200 (Airo TruCT). The best figure of merit score was for the Airo TruCT low dose, followed by Cios Spin medium dose and high dose.Conclusions
Selection of intraoperative imaging systems requires a greater understanding of the risks and benefits of radiation exposure and IQ.Item Open Access Interhospital Transfer delays care for spinal cord injury patients: A Report from the North American Clinical Trials Network for Spinal Cord Injury.(Journal of neurotrauma, 2023-04) Kelly-Hedrick, Margot; Ugiliweneza, Beatrice; Toups, Elizabeth G; Jimsheleishvili, George; Kurpad, Shekar N; Aarabi, Bizhan; Harrop, James S; Foster, Norah; Goodwin, Rory C; Shaffrey, Christopher I; Fehlings, Michael G; Tator, Charles H; Guest, James D; Neal, Chris J; Abd-El-Barr, Muhammad M; Williamson, TheresaThe North America Clinical Trials Network (NACTN) for Spinal Cord Injury (SCI) is a consortium of tertiary medical centers that has maintained a prospective SCI registry since 2004, and has espoused that early surgical intervention is associated with improved outcome. It has previously been shown that initial presentation to a lower acuity center and necessity of transfer to a higher acuity center reduce rates of early surgery. The NACTN database was evaluated to examine the association between interhospital transfer (IHT), early surgery, and outcome, taking into account distance traveled and site of origin for the patient. Data from a 15-year period of the NACTN SCI Registry were analyzed (years 2005-2019). Patients were stratified into transfers directly from the scene to a level I trauma center (NACTN site) versus IHT from a level II or III trauma facility. The main outcome was surgery within 24 hours of injury (yes/no) while secondary outcomes were length of stay, death, discharge disposition, and 6-month AIS grade conversion. For the IHT patients, distance traveled for transfer was calculated by measuring the shortest distance between origin and NACTN hospital. Analysis was performed with Brown-Mood test and chi-square tests. Of 724 patients with transfer data, 295 (40%) underwent IHT and 429 (60%) were admitted directly from the scene of accident. Patients who underwent IHT were more likely to have a less severe SCI (AIS D) (p=.002), have a central cord injury (p=.004), and have a fall as their mechanism of injury (p<.0001) than those directly admitted to a NACTN center. Of the 634 patients who had surgery, direct admission to a NACTN site was more likely to result in surgery within 24 hours compared to IHT patients (52% vs. 38%) (p< .0003). Median IHT distance was 28 miles (interquartile range=13-62 miles). There was no significant difference in death, length of stay, discharge to a rehab facility versus home, or 6-month AIS grade conversion rates between the two groups. Patients who underwent IHT to a NACTN site were less likely to have surgery within 24 hours of injury, compared to those directly admitted to the level I trauma facility. While there was no difference in mortality rates, length of stay, or 6-month AIS conversion between groups, patients with IHT were more likely be older with a less severe level of injury (AIS D). This work suggests there are barriers to timely recognition of SCI in the field, appropriate admission to a higher level of care after recognition, and challenges related to the management of individuals with less severe SCI.Item Open Access Interhospital transfer status for spinal metastasis patients in the United States is associated with more severe clinical presentations and higher rates of inpatient complications.(Neurosurgical focus, 2021-05) De la Garza Ramos, Rafael; Park, Christine; McCray, Edwin; Price, Meghan; Wang, Timothy Y; Dalton, Tara; Baëta, César; Erickson, Melissa M; Foster, Norah; Pennington, Zach; Shin, John H; Sciubba, Daniel M; Than, Khoi D; Karikari, Isaac O; Shaffrey, Christopher I; Abd-El-Barr, Muhammad M; Yassari, Reza; Goodwin, C RoryObjective
In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD.Methods
The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes.Results
Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18-1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16-1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46-1.98, p < 0.001), with no significant difference in inpatient mortality rates.Conclusions
Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.Item Open Access Management of Acute Traumatic Spinal Cord Injury: A Review of the Literature.(Frontiers in surgery, 2021-01) Wang, Timothy Y; Park, Christine; Zhang, Hanci; Rahimpour, Shervin; Murphy, Kelly R; Goodwin, C Rory; Karikari, Isaac O; Than, Khoi D; Shaffrey, Christopher I; Foster, Norah; Abd-El-Barr, Muhammad MTraumatic spinal cord injury (TSCI) is a debilitating disease that poses significant functional and economic burden on both the individual and societal levels. Prognosis is dependent on the extent of the spinal injury and the severity of neurological dysfunction. If not treated rapidly, patients with TSCI can suffer further secondary damage and experience escalating disability and complications. It is important to quickly assess the patient to identify the location and severity of injury to make a decision to pursue a surgical and/or conservative management. However, there are many conditions that factor into the management of TSCI patients, ranging from the initial presentation of the patient to long-term care for optimal recovery. Here, we provide a comprehensive review of the etiologies of spinal cord injury and the complications that may arise, and present an algorithm to aid in the management of TSCI.Item Open Access Objective Test Scores Throughout Orthopedic Surgery Residency Suggest Disparities in Training Experience.(Journal of surgical education, 2021-09) Foster, Norah; Price, Meghan; Bettger, Janet Prvu; Goodwin, C Rory; Erickson, MelissaDiversifying clinical residencies, particularly in fields that are historically dominated by majority male (M/M) cohorts, is critical to improve both the training experiences of residents and the overall physician workforce. Orthopedic surgery in particular has low numbers of females and under-represented minorities (F/URM) at all levels of training and practice. Despite efforts to increase its diversity, this field has become more homogeneous in recent years. To highlight potential barriers and disparate training environments that may contribute to this dynamic, we present 25 years' worth of institutional data on standardized exam performance throughout residency. We report that despite starting residency with standardized exam scores that were comparable to their M/M peers, F/URM orthopedic surgery residents performed progressively worse on Orthopaedic In-service Training Exams throughout residency and had lower first pass rates on the American Board of Orthopedic Surgery Part 1. Given these findings, we propose that disparate performance on standardized test scores throughout residency could identify trainees that may have different experiences that negatively impact their exam performance. Shedding light on these underlying disparities provides opportunities to find meaningful and sustained ways to develop a culture of diversity and inclusion. It may also allow for other programs to identify similar patterns within their training programs. Overall, we propose monitoring test performance on standardized exams throughout orthopedic surgery residency to identify potential disparities in training experience; further, we acknowledge that interventions to mitigate these disparities require a broad, systems wide approach and a firm institutional commitment to reducing bias and working toward sustainable change.Item Open Access Preoperative optimization for patients undergoing elective spine surgery.(Clinical neurology and neurosurgery, 2021-01-14) Wang, Timothy Y; Price, Meghan; Mehta, Vikram A; Bergin, Stephen M; Sankey, Eric W; Foster, Norah; Erickson, Melissa; Gupta, Dhanesh K; Gottfried, Oren N; Karikari, Isaac O; Than, Khoi D; Goodwin, C Rory; Shaffrey, Christopher I; Abd-El-Barr, Muhammad M