Evaluating the Migration Rates in Percutaneous Spinal Cord Stimulation Trials

Introduction: Spinal cord stimulation (SCS) provides symptom reduction in patients with chronic low back pain. The most common complication in SCS is percutaneous lead migration from initial placement site. It is our goal to determine whether using skin anchors during trial implantation reduces SCS trial lead migration rates compared to historical controls. Methods: 197 patients who underwent SCS trial placement at Thomas Jefferson University Hospital between 2015 and 2018 were considered for this study. Complete data including device impedance measurements and pre and post trial x-rays was collected on 12 historical control patients and 19 patients with leads secured using an anchor. Results: The mean degree of lead migration was not statistically significantly different between the anchor group and control group in the right lead (0.71 mm (95% CI -6.24, 7.66, p=0.84) and the left lead (-0.85 mm (95% CI -7.70, 6.00, p=0.80). Additionally, there was no statistical difference in device impedance from the first day of the trial to the trial removal date between the anchor group and control group (-47.35 Ohms (95% CI -181.48, 86.78, p=0.47). Discussion: There was no significant reduction in lead migration or device impedance measurement in patients who underwent trial SCS with leads secured with an anchor compared to historical controls. This raises the question of whether the anchoring technique successfully reduces lead migration and emphasizes the importance of obtaining pre and post trial x-rays to evaluate lead migration

Addressing the Limitations of Neurosurgical Care via Telemedicine

Novel telemedicine software successfully automates cranial nerve assessment of patients from the comfort of their hom

The ARUBA Trial: How Should We Manage Brain AVMs?

BACKGROUND Brain arteriovenous malformations (bAVMs) are abnormal shunts that bypass the capillary bed and directly divert blood from the arterial to the venous circulation, without exchanging nutrients or dissipating the arterial blood pressure. They are thought to be congenital vascular lesions that occur during the late stages of fetal development, however the exact pathogenesis has not been elucidated yet.1 History of hemorrhage, small AVM size, high arterial feeding blood pressure, and deep venous drainage are the main risk factors that increase the likelihood of AVM rupture. According to the American Stroke Association, 1 in 200-500 people have an AVM, while 25% of AVM patients experience seizures and 50% of patients suffer intracranial hemorrhage (ICH) at some point in their lives.2 Also, 5-15% of AVM patients experience severe headaches because of the increased intracranial pressure and a similar percentage of patients exhibit neurological deficits.1 With the advent of noninvasive imaging, AVMs are being detected at an early, unruptured stage, but the optimal course of action for preventing future complications still remains uncertain. The ARUBA trial strove to determine whether medical management or interventional therapy has a better long-term outcome for patients with unruptured AVMs. While it provides important data, limitations in its study design raise doubts concerning the generalizability of its findings. The study planned to include 800 patients who were to be followed for a minimum of five and a maximum of seven years.3 They were randomly assigned to one of two groups, the interventional therapy and medical management group. Patients in the medical management group received only pharmacological therapy for the medical symptoms that they experienced (unless they developed hemorrhage or infarction, in which case they were switched into the other group). Patients in the interventional therapy group received endovascular surgery, microsurgery, or radiosurgery, with or without pharmacological therapy depending on their concurrent medical conditions. The primary hypothesis was that medical management is more effective in the treatment of patients with unruptured bAVMs, the primary endpoint was death or stroke, the secondary endpoint was the quality of life, while the functional outcome status was measured using the Rankin scale.3 Previous studies had shown that early interventional treatment in patients with ruptured bAVMs is necessary and patients did not have major future clinical problems.3 Interventional therapy includes endovascular surgery, which aims to occlude the nidus by delivering liquid embolics or embolic coils via a catheter, microsurgical resection of the AVM, or radiosurgery that induces a vascular injury response resulting in AVM obliteration within 1 or 2 years.1 A multimodal therapy that involves more than one of these interventional procedures can also be performed on certain patients. Furthermore, medical management was shown to be very effective in treating unruptured bAVMs as indicated by the very low rate of future hemorrhage. Yet, based on data from the Columbia University Medical Center, interventional treatment of ruptured AVMs had a significantly greater likelihood of hemorrhage and/or clinical impairment (Rankin score ≥2) than medical management of unruptured AVMs. It is thus imperative to compare the effectiveness of the two methods of treatment only on patients with unruptured bAVMs, since patients who present with an ICH have an already much higher risk of experiencing a subsequent ICH (hazard ratio of 3.6).4 The ARUBA trial is the first study comparing medical management to surgical care on patients with unruptured bAVMs and a Rankin score less than two.

Comparative Observational Study for Bifurcating aneurysm treatment; open versus endovascular approaches and classical versus new techniques.

Introduction: Aneurysm occur in approximately 3.2% of the population with a mean age of 50 years, a 1:1 gender ratio, and an estimate mortality rate of 70%. Aneurysms develop at branch points with elevated intravascular turbulence and vessel wall shear stress. we aim to compare the efficacy and safety of different surgical treatment modalities for bifurcating intracranial aneurysms. Methods: A retrospective review of 398 patients who underwent surgical management of a bifurcating aneurysm at Thomas Jefferson University hospital from 2010 to 2020. Aneurysm size, location, modality of treatment, and treatment complications were assessed. Results: Data analysis is expected to return from the statistician in early to mid-December. Data analysis has not been returned to date. Discussion: We hypothesize that those treated with endovascular techniques have better outcomes than those who received intracranial clippings. Additionally, we expect that coil embolization will have better results for saccular aneurysms, while balloon assisted stenting or stent assisted coiling of aneurysm will provide better outcomes for fusiform aneurysms. If these hypotheses hold true, then our data will suggest that there are specific surgical treatment modalities that improve patient outcomes based upon aneurysm type

Improving the Virtual Neurosurgery Residency Interview Experience

The residency selection process has proven a challenge in the face of the Covid-19 pandemic. In the neurosurgery match, residents are chosen based on objective metrics as well as their ability to effectively work as part of a team tasked with caring for medically complex patients faced with neurosurgical conditions. As there remain limitations on the number of externships students could participate in and the Step 1 examination is expected to be reported as either pass or fail in years to come, we will have fewer objective metrics to review in the student application. We conducted a study to best select neurosurgery resident applicants who could effectively work with our team to ultimately provide effective patientcentered care. Through a post-interview survey among applicants, we identified points of improvements for the neurosurgery residency application interview

Improving Serial Imaging Protocols in Spontaneous Intracerebral Hemorrhage

There is no universally agreed upon protocol to image patient presenting with intra-parenchymal hemorrhage of non-traumatic etiology (sICH). At our institution, it is common practice for a patient to have 3 CT’s done within 24 hours. They are often at onset of symptoms or presentation, 6 hours post onset of symptoms, and finally 24 hours post bleed onset. The goal of this project will be to assess the safety and efficacy of obtaining this repeat imaging in our patients in the hopes that limiting unnecessary CT head studies will decrease resource utilization, decrease patient radiation, expedite movement of stable patients out of the ICU and/or disposition

Establishing Cost-effective Management of Postoperative Urinary Retention after Spine Surgery

Goal Our goal is to develop evidence-based guidelines that: streamline the order/timing of interventions in patients who develop PUR after spine surgery identify those at high-risk of long-term urinary retention that require further workup minimize the rate of PUR –goal is to reduce to 3.5% in FY 2019 and determine the cost savings from our intervention when applied to all surgerieshttps://jdc.jefferson.edu/patientsafetyposters/1085/thumbnail.jp

Neuroimaging Protocol in Patients Presenting with Spontaneous Intracerebral Hemorrhage

Introduction While lacking evidence based recommendations, most institutions must evaluate spontaneous intracerebral hemorrhages (sICH) for hematoma expansion (HE). If unrecognized, it can be a devastating complication. However, because of the lack of general recommendations for serial imaging, many hospitals, including Thomas Jefferson, have arbitrarily instituted 6 hour an 24 hour stability head CT’s to evaluate for HE. In our project, we examine the impact of this imaging protocol on the safety and quality of patient care and provide revised recommendations for imaging in sICH at Thomas Jefferson University Hospital and Jefferson Hospital for Neuroscience.https://jdc.jefferson.edu/patientsafetyposters/1110/thumbnail.jp

Improving Serial Imaging Protocols in Spontaneous Intracerebral Hemorrhage

The goal of this project has been to decrease unnecessary serial imaging in our patients in order to decrease resource utilization, decrease patient radiation, expedite movement of stable patients out of the ICU and/or dispositio