Dr. John Ratliff is Associate Professor and Vice Chair of Neurosurgery, Departmental Quality Officer, and Co-Director of the Spine and Peripheral Nerve Surgery Division. As a spine surgeon, he treats a diverse array of degenerative spinal conditions. He has a specific research emphasis on quality improvement, decreasing complications in spine surgery, and improving surgical treatment of intramedullary spinal cord tumors.

Dr. Ratliff serves on the Executive Committee of the Congress of Neurological Surgeons and the Joint Section of Disorders of Spine and Peripheral Nerves, is Corresponding Secretary for the Council of State Neurosurgical Societies, and is on the Board of Directors of Neuropoint Alliance. He is chairman of the joint AANS/CNS Neurosurgery Quality Council.

Clinical Focus

  • Adult reconstructive spinal surgery
  • Spinal cord neoplasms
  • Spinal stenosis
  • Minimally invasive spinal surgery
  • Spinal metastatic disease
  • Spinal disc herniation
  • Radiosurgery of spinal tumors
  • Peripheral Nerve Neoplasms
  • Neurological Surgery

Academic Appointments

Administrative Appointments

  • Instructor, New York University, Manhattan Veteran's Affairs Medical Center, Bellevue Medical Center, New York University, New York, New York (2001 - 2002)
  • Assistant Professor, Rush University School of Medicine, Chicago, Illinois (2002 - 2005)
  • Director of Spine and Peripheral Nerve Surgery, Rush University School of Medicine, Chicago, Illinois (2002 - 2005)
  • Assistant Professor, Thomas Jefferson University, Philadelphia, Pennsylvania (2005 - 2008)
  • Associate Professor, Thomas Jefferson University, Philadelphia, Pennsylvania (2008 - 2011)
  • Associate Professor, Stanford University School of Medicine (2011 - Present)
  • Co-Director, Division of Spine and Peripheral Nerve Surgery, Department of Neurosurgery, Stanford University (2011 - Present)
  • Chair, Quality Improvement Workgroup, American Association of Neurological Surgeons/Congress of Neurological Surgeons (2010 - Present)
  • Corresponding Secretary, Council of State Neurosurgical Societies (2015 - 2016)
  • Member at Large, Congress of Neurological Surgeons (2014 - 2016)
  • Vice Chair, Operations and Development, Department of Neurosurgery, Stanford University (2013 - Present)

Honors & Awards

  • Charlie Kuntz Scholar Award, AANS/CNS Disorders of Spine and Peripheral Nerves Joint Section (2016)
  • Denise O'Leary Award for Clinical Excellence, Stanford University Hospital and Clinics Board of Directors (2015)
  • Top Oral Platform Presentation, AANS/CNS Disorders of Spine and Peripheral Nerves Joint Section (2015)
  • Stanford University Department of Neurosurgery Excellence in Education and Mentorship Award, Stanford University Department of Neurosurgery (2013)
  • Walsh Foundation Research Grant, Walsh Foundation (2013)
  • Orthopedic Research and Education Foundation research grant award, Orthopedic Research and Education Foundation (2012)
  • Robert Florin, MD Award for Excellence in Research, American Association of Neurological Surgeons (2010)
  • Brandeis University Health Policy Leaders Program Scholarship, American College of Surgeons (2009)
  • Chicago Institute for Neurosurgery and Neuroresearch Foundation Research Grant, Chicago Institute of Neurosurgery and Neuroresearch Foundation (2003)

Professional Education

  • Board Certification: Neurological Surgery, American Board of Neurological Surgery (2005)
  • Fellowship:New York University Medical Center (2002) NY
  • Residency:Louisiana State University - New Orleans (2001) LA
  • Internship:Louisiana State University - New Orleans (1996) LA
  • Medical Education:Tulane University School of Medicine (1995) LA
  • MD, Tulane Medical School, Medicine (1995)

Research & Scholarship

Current Research and Scholarly Interests

At present, I am working on a prospective measure to assess the risk of complications in spine surgery procedures. I am studying the impact of patient disease process, choice of operative approach, and patient pre-operative comorbidities on complication occurrence. The goal of this effort will be to develop a clinical tool that may be used in patient counseling.

Presently, a prospectively developed measure of comorbidities is being modeled to ICD-9 nomencature for use in the Nationwide Inpatient Sample database.

My longer term research goals are to develop clearer means of assessing outcomes in spine surgery procedures and developing patient-centered outcomes assessments that may be scalable for larger populations.

Clinical Trials

  • Restore CLINICAL TRIAL Recruiting

    This is a prospective, concurrently controlled, multi-center study to evaluate the safety and effectiveness of the Spinal Kinetics M6-C artificial cervical disc compared to anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical radiculopathy with or without cord compression. Some participating sites will enroll just M6-C patients, while others will enroll just ACDF patients. Patients eligible for study enrollment will present with degenerative cervical radiculopathy requiring surgical intervention, confirmed clinically and radiographically, at one vertebral level from C3 to C7. A total of 243 subjects will be included at up to 20 sites.

    View full details

  • MR Guided High Intensity Focused Ultrasound for Lumbar Back Pain Recruiting

    The primary purpose of this protocol is to assess the ExAblate 2100 MR guided high intensity focused ultrasound device as an intervention for treatment of facetogenic lower back pain.

    View full details


2016-17 Courses


All Publications

  • Predicting Occurrence of Spine Surgery Complications Using "Big Data" Modeling of an Administrative Claims Database JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Ratliff, J. K., Balise, R., Veeravagu, A., Cole, T. S., Cheng, I., Olshen, R. A., Tian, L. 2016; 98 (10): 824-834


    Postoperative metrics are increasingly important in determining standards of quality for physicians and hospitals. Although complications following spinal surgery have been described, procedural and patient variables have yet to be incorporated into a predictive model of adverse-event occurrence. We sought to develop a predictive model of complication occurrence after spine surgery.We used longitudinal prospective data from a national claims database and developed a predictive model incorporating complication type and frequency of occurrence following spine surgery procedures. We structured our model to assess the impact of features such as preoperative diagnosis, patient comorbidities, location in the spine, anterior versus posterior approach, whether fusion had been performed, whether instrumentation had been used, number of levels, and use of bone morphogenetic protein (BMP). We assessed a variety of adverse events. Prediction models were built using logistic regression with additive main effects and logistic regression with main effects as well as all 2 and 3-factor interactions. Least absolute shrinkage and selection operator (LASSO) regularization was used to select features. Competing approaches included boosted additive trees and the classification and regression trees (CART) algorithm. The final prediction performance was evaluated by estimating the area under a receiver operating characteristic curve (AUC) as predictions were applied to independent validation data and compared with the Charlson comorbidity score.The model was developed from 279,135 records of patients with a minimum duration of follow-up of 30 days. Preliminary assessment showed an adverse-event rate of 13.95%, well within norms reported in the literature. We used the first 80% of the records for training (to predict adverse events) and the remaining 20% of the records for validation. There was remarkable similarity among methods, with an AUC of 0.70 for predicting the occurrence of adverse events. The AUC using the Charlson comorbidity score was 0.61. The described model was more accurate than Charlson scoring (p < 0.01).We present a modeling effort based on administrative claims data that predicts the occurrence of complications after spine surgery.We believe that the development of a predictive modeling tool illustrating the risk of complication occurrence after spine surgery will aid in patient counseling and improve the accuracy of risk modeling strategies.

    View details for DOI 10.2106/JBJS.15.00301

    View details for Web of Science ID 000378644500009

    View details for PubMedID 27194492

  • Building an electronic health record integrated quality of life outcomes registry for spine surgery JOURNAL OF NEUROSURGERY-SPINE Azad, T. D., Kalani, M., Wolf, T., Kearney, A., Lee, Y., Flannery, L., Chen, D., Berroya, R., Eisenberg, M., Park, J., Shuer, L., Kerr, A., Ratliff, J. K. 2016; 24 (1): 176-185
  • Intraoperative Neuromonitoring in Single-Level Spinal Procedures A Retrospective Propensity Score-Matched Analysis in a National Longitudinal Database SPINE Cole, T., Veeravagu, A., Zhang, M., Li, A., Ratliff, J. K. 2014; 39 (23): 1950-1959
  • Usage of recombinant human bone morphogenetic protein in cervical spine procedures: analysis of the MarketScan longitudinal database. journal of bone and joint surgery. American volume Cole, T., Veeravagu, A., Jiang, B., Ratliff, J. K. 2014; 96 (17): 1409-1416


    Usage of recombinant human bone morphogenetic protein (rhBMP) in anterior cervical discectomy and fusion (ACDF) procedures is controversial. Studies suggest increased rates of dysphagia, hematoma or seroma, and severe airway compromise in anterior cervical spine procedures using rhBMP. The purpose of the present study was to determine and describe national utilization trends and complication rates associated with rhBMP usage in anterior cervical spine procedures.The MarketScan database from 2006 to 2010 was retrospectively queried to identify 91,543 patients who underwent ACDF with or without cervical corpectomy. Patient selection and outcomes were ascertained with use of ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) and CPT (Current Procedural Terminology) coding. A total of 3197 patients were treated with rhBMP intraoperatively. Mean follow-up was 588 days (interquartile range [IQR], 205 to 886 days) in the non-treated cohort and 591 days (IQR, 203 to 925 days) in the rhBMP-treated cohort. Multivariate logistic regression as well as propensity score analysis were used to evaluate the association of rhBMP usage with postoperative complications.In propensity score-adjusted models, rhBMP usage was associated with an increased risk of any complication (odds ratio [OR] = 1.34, 95% confidence interval [CI] = 1.2 to 1.5) and specific complications such as hematoma or seroma (OR = 1.8, 95% CI = 1.4 to 2.3), dysphagia (OR = 1.3, 95% CI = 1.1 to 1.5), and any pulmonary complication (OR = 1.5, 95% CI = 1.2 to 1.8) within thirty days postoperatively. There were no significant differences in the rates of readmission, in-hospital mortality, referral to pain management, new malignancy, or reoperation between the two cohorts. Usage of rhBMP was associated with a mean increase of $5545 (19%) in total payments to the hospital and primary physician (p < 0.001).We found an increased overall rate of postoperative complications in patients receiving rhBMP for cervical spinal fusion procedures compared with patients not receiving rhBMP. Hematoma or seroma, pulmonary complications, and dysphagia were also more common in the rhBMP cohort. Usage of rhBMP in a case was associated with $311 greater payments to the surgeon and $4213 greater payments to the hospital.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

    View details for DOI 10.2106/JBJS.M.01016

    View details for PubMedID 25187578

  • The perils of comparative effectiveness, cost-effectiveness, and value of care research: lessons learned from washington state. Neurosurgery Ratliff, J. K. 2014; 61: 12-15

    View details for DOI 10.1227/NEU.0000000000000385

    View details for PubMedID 25032524

  • Impact of bone morphogenetic proteins on frequency of revision surgery, use of autograft bone, and total hospital charges in surgery for lumbar degenerative disease: review of the Nationwide Inpatient Sample from 2002 to 2008 SPINE JOURNAL Dagostino, P. R., Whitmore, R. G., Smith, G. A., Maltenfort, M. G., Ratliff, J. K. 2014; 14 (1): 20-30


    BACKGROUND CONTEXT: Bone morphogenetic proteins (BMPs) were developed with the goal of improving clinical outcomes through the promotion of bony healing and reducing morbidity from iliac crest bone graft harvest. PURPOSE: To complete a population-based assessment of the impact of BMP on use of autograft, rates of operative treatment for lumbar pseudoarthrosis, and hospital charges. STUDY DESIGN: Nationwide Inpatient Sample (NIS) retrospective cohort assessment of 46,452 patients from 2002 to 2008. PATIENT SAMPLE: All patients who underwent lumbar arthrodesis procedures for degenerative spinal disease. OUTCOME MEASURES: Use of BMP, revision surgery status as a percentage of total procedures, and autograft harvest in lumbar fusion procedures completed for degenerative diagnoses. METHODS: Demographic and geographic/practice data, hospital charges, and length of stay of all NIS patients with thoracolumbar and lumbosacral procedure codes for degenerative spinal diagnoses were recorded. Codes for autograft harvest, use of BMP, and revision surgery were included in multivariable regression analysis. RESULTS: The assessment found 46,452 patients from 2002 to 2008 undergoing thoracolumbar or lumbar arthrodesis procedures for degenerative disease. Assuming a representative sample, this cohort models more than 200,000 US patients. There was steady growth in lumbar spine fusion and in the use of BMP. The use of BMP increased from 2002 to 2008 (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.48-1.52). Revision procedures decreased over the study period (OR, 0.94; 95% CI, 0.91-0.96). The use of autograft decreased substantially after introduction of BMP but then returned to baseline levels; there was no net change in autograft use from 2002 to 2008. The use of BMP correlated with significant increases in hospital charges ($13,362.39; standard deviation±596.28, p<.00001). The use of BMP in degenerative thoracolumbar procedures potentially added more than $900 million to hospital charges from 2002 to 2008. CONCLUSIONS: There was an overall decrease in rates of revision fusion procedures from 2002 to 2008. Introduction of BMP did not correlate with decrease in use of autograft bone harvest. Use of BMP correlated with substantial increase in hospital charges. The small decrease in revision surgeries recorded, combined with lack of significant change in autograft harvest rates, may question the financial justification for the use of BMP.

    View details for DOI 10.1016/j.spinee.2012.10.035

    View details for Web of Science ID 000328496600007

    View details for PubMedID 23218827

  • ASA grade and Charlson Comorbidity Index of spinal surgery patients: correlation with complications and societal costs SPINE JOURNAL Whitmore, R. G., Stephen, J. H., Vernick, C., Campbell, P. G., Yadla, S., Ghobrial, G. M., Maltenfort, M. G., Ratliff, J. K. 2014; 14 (1): 31-38


    The Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA grade) are useful for predicting morbidity and mortality for a variety of disease processes.To evaluate CCI and ASA grade as predictors of complications after spinal surgery and examine the correlation between these comorbidity indices and the cost of care.Prospective observational study.All patients undergoing any spine surgery at a single academic tertiary center over a 6-month period.Direct health-care costs estimated from diagnosis related group and Current Procedural Terminology (CPT) codes.Demographic data, including all patient comorbidities, procedural data, and all complications, occurring within 30 days of the index procedure were prospectively recorded. Charlson Comorbidity Index was calculated from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ASA grades determined from the operative record. Diagnosis related group and CPT codes were captured for each patient. Direct costs were estimated from a societal perspective using Medicare rates of reimbursement. A multivariable analysis was performed to assess the association of the CCI and ASA grade to the rate of complication and direct health-care costs.Two hundred twenty-six cases were analyzed. The average CCI score for the patient cohort was 0.92, and the average ASA grade was 2.65. The CCI and ASA grade were significantly correlated, with Spearman ρ of 0.458 (p<.001). Both CCI and ASA grade were associated with increasing body mass index (p<.01) and increasing patient age (p<.0001). Increasing CCI was associated with an increasing likelihood of occurrence of any complication (p=.0093) and of minor complications (p=.0032). Increasing ASA grade was significantly associated with an increasing likelihood of occurrence of a major complication (p=.0035). Increasing ASA grade showed a significant association with increasing direct costs (p=.0062).American Society of Anesthesiologists and CCI scores are useful comorbidity indices for the spine patient population, although neither was completely predictive of complication occurrence. A spine-specific comorbidity index, based on ICD-9-CM coding that could be easily captured from patient records, and which is predictive of patient likelihood of complications and mortality, would be beneficial in patient counseling and choice of operative intervention.

    View details for DOI 10.1016/j.spinee.2013.03.011

    View details for Web of Science ID 000328496600008

    View details for PubMedID 23602377

  • Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study THE SPINE JOURNAL Veeravagu, A., Cole, T., Jiang, B., Ratliff, J. K. 2013
  • Patient comorbidity score predicting the incidence of perioperative complications: assessing the impact of comorbidities on complications in spine surgery Clinical article JOURNAL OF NEUROSURGERY-SPINE Campbell, P. G., Yadla, S., Nasser, R., Malone, J., Maltenfort, M. G., Ratliff, J. K. 2012; 16 (1): 37-43


    Present attempts to control health care costs focus on reducing the incidence of complications and hospital-acquired conditions (HACs). One approach uses restriction or elimination of hospital payments for HACs. Present approaches assume that all HACs are created equal and that payment restrictions should be applied uniformly. Patient factors, and especially patient comorbidities, likely impact complication incidence. The relationship of patient comorbidities and complication incidence in spine surgery has not been prospectively reported.The authors conducted a prospective assessment of complications in spine surgery during a 6-month period; an independent auditor and a validated definition of perioperative complications were used. Initial demographics captured relevant patient comorbidities. The authors constructed a model of relative risk assessment based on the presence of a variety of comorbidities. They examined the impact of specific comorbidities and the cumulative effect of multiple comorbidities on complication incidence.Two hundred forty-nine patients undergoing 259 procedures at a tertiary care facility were evaluated during the 6-month duration of the study. Eighty percent of the patients underwent fusion procedures. One hundred thirty patients (52.2%) experienced at least 1 complication, with major complications occurring in 21.4% and minor complications in 46.4% of the cohort. Major complications doubled the median duration of hospital stay, from 6 to 12 days in cervical spine patients and from 7 to 14 days in thoracolumbar spine patients. At least 1 comorbid condition was present in 86% of the patients. An increasing number of comorbidities strongly correlated with increased risk of major, minor, and any complications (p = 0.017, p < 0.0001, and p < 0.0001, respectively). Patient factors correlating with increased risk of specific complications included systemic malignancy and cardiac conditions other than hypertension.Comorbidities significantly increase the risk of perioperative complications. An increasing number of comorbidities in an individual patient significantly increases the risk of a perioperative adverse event. Patient factors significantly impact the relative risk of HACs and perioperative complications.

    View details for DOI 10.3171/2011.9.SPINE11283

    View details for Web of Science ID 000298631100009

    View details for PubMedID 22035101

  • Geographic variation and regional trends in adoption of endovascular techniques for cerebral aneurysms JOURNAL OF NEUROSURGERY Smith, G. A., Dagostino, P., Maltenfort, M. G., Dumont, A. S., Ratliff, J. K. 2011; 114 (6): 1768-1777


    Considerable evolution has occurred in treatment options for cerebral aneurysms. Development of endovascular techniques has produced a significant change in the treatment of ruptured and unruptured intracranial aneurysms. Adoption of endovascular techniques and increasing numbers of patients undergoing endovascular treatment may affect health care expenditures. Geographic assessment of growth in endovascular procedures has not been assessed.The National Inpatient Sample (NIS) was queried for ICD-9 codes for clipping and coiling of ruptured and unruptured cerebral aneurysms from 2002 to 2008. Patients with ruptured and unruptured cerebral aneurysms were compared according to in-hospital deaths, hospital length of stay, total hospital cost, and selected procedure. Hospital costs were adjusted to bring all costs to 2008 equivalents. Regional variation over the course of the study was explored.The NIS recorded 12,588 ruptured cerebral aneurysm cases (7318 clipped and 5270 coiled aneurysms) compared with 11,606 unruptured aneurysm cases (5216 clipped and 6390 coiled aneurysms), representing approximately 121,000 aneurysms treated in the study period. Linear regression analysis found that the number of patients treated endovascularly increased over time, with the total number of endovascular patients increasing from 17.28% to 57.59% for ruptured aneurysms and from 29.70% to 62.73% for unruptured aneurysms (p < 0.00001). Patient age, elective status, and comorbidities increased the likelihood of endovascular treatment (p < 0.00001, p < 0.00004, and p < 0.02, respectively). In patients presenting with subarachnoid hemorrhage (SAH), endovascular treatments were more commonly chosen in urban and academic medical centers (p = 0.009 and p = 0.05, respectively). In-hospital deaths decreased over the study period in patients with both ruptured and unruptured aneurysms (p < 0.00001); presentation with SAH remained the single greatest predictor of death (OR 38.09, p < 0.00001). Geographic analysis showed growth in endovascular techniques concentrated in eastern and western coastal states, with substantial variation in adoption of endovascular techniques (range of percentage of endovascular patients [2008] 0%-92%). There were higher costs in patients treated endovascularly, but these differences were likely secondary to presenting diagnosis and site-of-service variations.The NIS database reveals a significant increase in the use of endovascular techniques, with the majority of both ruptured and unruptured aneurysms treated endovascularly by 2008. Differences in hospital costs between open and endovascular techniques are likely secondary to patient and site-of-service factors. Presentation with SAH was the primary factor affecting hospital cost and a greater percentage of endovascular procedures completed at urban academic medical centers. There is substantial regional variation in the adoption of endovascular techniques.

    View details for Web of Science ID 000291123300051

    View details for PubMedID 21314274

  • Comparison of ICD-9 based, retrospective, and prospective assessments of perioperative complications assessment of accuracy in reporting Clinical article JOURNAL OF NEUROSURGERY-SPINE Campbell, P. G., Malone, J., Yadla, S., Chitale, R., Nasser, R., Maltenfort, M. G., Vaccaro, A., Ratliff, J. K. 2011; 14 (1): 16-22


    large studies of ICD-9-based complication and hospital-acquired condition (HAC) chart reviews have not been validated through a comparison with prospective assessments of perioperative adverse event occurrence. Retrospective chart review, while generally assumed to underreport complication occurrence, has not been subjected to prospective study. It is unclear whether ICD-9-based population studies are more accurate than retrospective reviews or are perhaps equally susceptible to bias. To determine the validity of an ICD-9-based assessment of perioperative complications, the authors compared a prospective independent evaluation of such complications with ICD-9-based HAC data in a cohort of patients who underwent spine surgery. For further comparison, a separate retrospective review of the same cohort of patients was completed as well.a prospective assessment of complications in spine surgery over a 6-month period (May to December 2008) was completed using an independent auditor and a validated definition of perioperative complications. The auditor maintained a prospective database, which included complications occurring in the initial 30 days after surgery. All medical adverse events were included in the assessment. All patients undergoing spine surgery during the study period were eligible for inclusion; the only exclusionary criterion used was the availability of the auditor for patient assessment. From the overall patient database, 100 patients were randomly extracted for further review; in these patients ICD-9-based HAC data were obtained from coder data. Separately, a retrospective assessment of complication incidence was completed using chart and electronic medical record review. The same definition of perioperative adverse events and the inclusion of medical adverse events were applied in the prospective, ICD-9-based, and retrospective assessments.ninety-two patients had adequate records for the ICD-9 assessment, whereas 98 patients had adequate chart information for retrospective review. The overall complication incidence among the groups was similar (major complications: ICD-9 17.4%, retrospective 19.4%, and prospective 22.4%; minor complications: ICD-9 43.8%, retrospective 31.6%, and prospective 42.9%). However, the ICD-9-based assessment included many minor medical events not deemed complications by the auditor. Rates of specific complications were consistently underreported in both the ICD-9 and the retrospective assessments. The ICD-9 assessment underreported infection, the need for reoperation, deep wound infection, deep venous thrombosis, and new neurological deficits (p = 0.003, p < 0.0001, p < 0.0001, p = 0.0025, and p = 0.04, respectively). The retrospective review underestimated incidences of infection, the need for revision, and deep wound infection (p < 0.0001 for each). Only in the capture of new cardiac events was ICD-9-based reporting more accurate than prospective data accrual (p = 0.04). The most sensitive measure for the appreciation of complication occurrence was the prospective review, followed by the ICD-9-based assessment (p = 0.05).an ICD-9-based coding of perioperative adverse events and major complications in a cohort of spine surgery patients revealed an overall complication incidence similar to that in a prospectively executed measure. In contrast, a retrospective review underestimated complication incidence. The ICD-9-based review captured many medical events of limited clinical import, inflating the overall incidence of adverse events demonstrated by this approach. In multiple categories of major, clinically significant perioperative complications, ICD-9-based and retrospective assessments significantly underestimated complication incidence. These findings illustrate a significant potential weakness and source of inaccuracy in the use of population-based ICD-9 and retrospective complication recording.

    View details for DOI 10.3171/2010.9.SPINE10151

    View details for Web of Science ID 000285669700007

    View details for PubMedID 21142455

  • Impact of Inpatient Venous Thromboembolism Continues After Discharge: Retrospective Propensity Scored Analysis in a Longitudinal Database. Clinical spine surgery Li, A. Y., Azad, T. D., Veeravagu, A., Bhatti, I., Li, A., Cole, T., Desai, A., Ratliff, J. K. 2016: -?


    Propensity score matched retrospective study using a nationwide longitudinal database.To quantify the longitudinal economic impact of venous thromboembolism (VTE) complications in spinal fusion patients.VTE is a rare and serious complication that may occur after spine surgery. The long-term socioeconomic impact understanding of these events has been limited by small sample sizes and a lack of longitudinal follow-up. We provide a comparative economic outcomes analysis of these complications.We identified 204,308 patients undergoing spinal fusion procedures in a national billing claims database (MarketScan) between 2006 and 2010. Cohorts were balanced using 50:1 propensity score matching and outcome measures compared at 6, 12, and 18 months postoperation.A total of 1196 (0.6%) patients developed postoperative VTE, predominantly occurring following lumbar fusion (69.7%). Postoperative VTE patients demonstrated an increase in hospital length of stay (7.8 vs. 3.3 d, P<0.001) and a decreased likelihood of being discharged home (71% vs. 85%, P<0.001). A $26,306 increase in total hospital payments (P<0.001) was observed, with a disproportionate increase seen in hospital payments ($22,103, P<0.001), relative to physician payments ($1766, P=0.001).At 6, 12, and 18 months postfusion, increased rates of readmission and follow-up clinic visits were observed. Delayed readmissions were associated with decreased length of stay (3.6 vs. 4.6 d, P<0.001), but increased total payments, averaging at $21,270 per readmission. VTE patients generated greater cumulative outpatient service payments, costing $8075, $11,134, and $13,202 more at 6, 12, and 18 months (P<0.001).VTEs are associated with longer hospitalizations, a decreased likelihood of being discharged home, and overall increases of hospital resource utilization and cost in inpatient and outpatient settings. VTE patients generate greater charges in the outpatient setting and are more likely to become readmitted at 6, 12, and 18 months after surgery, demonstrating a significant socioeconomic impact long after occurrence.Level III-therapeutic.

    View details for PubMedID 27750270

  • An assessment of data and methodology of online surgeon scorecards. Journal of neurosurgery. Spine Xu, L. W., Li, A., Swinney, C., Babu, M., Veeravagu, A., Wolfe, S. Q., Nahed, B. V., Ratliff, J. K. 2016: 1-8


    OBJECTIVE Recently, 2 surgeon rating websites (Consumers' Checkbook and ProPublica) were published to allow the public to compare surgeons through identifying surgeon volume and complication rates. Among neurosurgeons and orthopedic surgeons, only cervical and lumbar spine, hip, and knee procedures were included in this assessment. METHODS The authors examined the methodology of each website to assess potential sources of inaccuracy. Each online tool was queried for reports on neurosurgeons specializing in spine surgery and orthopedic surgeons specializing in spine, hip, or knee surgery. Surgeons were chosen from top-ranked hospitals in the US, as recorded by a national consumer publication ranking system, within the fields of neurosurgery and orthopedic surgery. The results were compared for accuracy and surgeon representation, and the results of the 2 websites were also compared. RESULTS The methodology of each site was found to have opportunities for bias and limited risk adjustment. The end points assessed by each site were actually not complications, but proxies of complication occurrence. A search of 510 surgeons (401 orthopedic surgeons [79%] and 109 neurosurgeons [21%]) showed that only 28% and 56% of surgeons had data represented on Consumers' Checkbook and ProPublica, respectively. There was a significantly higher chance of finding surgeon data on ProPublica (p < 0.001). Of the surgeons from top-ranked programs with data available, 17% were quoted to have high complication rates, 13% with lower volume than other surgeons, and 79% had a 3-star out of 5-star rating. There was no significant correlation found between the number of stars a surgeon received on Consumers' Checkbook and his or her adjusted complication rate on ProPublica. CONCLUSIONS Both the Consumers' Checkbook and ProPublica websites have significant methodological issues. Neither site assessed complication occurrence, but rather readmissions or prolonged length of stay. Risk adjustment was limited or nonexistent. A substantial number of neurosurgeons and orthopedic surgeons from top-ranked hospitals have no ratings on either site, or have data that suggests they are low-volume surgeons or have higher complication rates. Consumers' Checkbook and ProPublica produced different results with little correlation between the 2 websites in how surgeons were graded. Given the significant methodological issues, incomplete data, and lack of appropriate risk stratification of patients, the featured websites may provide erroneous information to the public.

    View details for PubMedID 27661563

  • Delayed Presentation of Sciatic Nerve Injury after Total Hip Arthroplasty: Neurosurgical Considerations, Diagnosis, and Management. Journal of neurological surgery reports Xu, L. W., Veeravagu, A., Azad, T. D., Harraher, C., Ratliff, J. K. 2016; 77 (3): e134-8


    Total hip arthroplasty (THA) is an established treatment for end-stage arthritis, congenital deformity, and trauma with good long-term clinical and functional outcomes. Delayed sciatic nerve injury is a rare complication after THA that requires prompt diagnosis and management.We present a case of sciatic nerve motor and sensory deficit in a 52-year-old patient 2 years after index left THA. Electromyography (EMG) results and imaging with radiographs and CT of the affected hip demonstrated an aberrant acetabular cup screw in the posterior-inferior quadrant adjacent to the sciatic nerve.The patient underwent surgical exploration that revealed injury to the peroneal division of the sciatic nerve due to direct injury from screw impingement. A literature review identified 11 patients with late-onset neuropathy after THA. Ten patients underwent surgical exploration and pain often resolved after surgery with 56% of patients recovering sensory function and 25% experiencing full recovery of motor function.Delayed neuropathy of the sciatic nerve is a rare complication after THA that is most often due to hardware irritation, component failure, or wear-related pseudotumor formation. Operative intervention is often pursued to explore and directly visualize the nerve with limited results in the literature showing modest relief of pain and sensory symptoms and poor restoration of motor function.

    View details for DOI 10.1055/s-0035-1568134

    View details for PubMedID 27602309

  • Surgical outcomes of cervical spondylotic myelopathy: an analysis of a national, administrative, longitudinal database. Neurosurgical focus Veeravagu, A., Connolly, I. D., Lamsam, L., Li, A., Swinney, C., Azad, T. D., Desai, A., Ratliff, J. K. 2016; 40 (6): E11-?


    OBJECTIVE The authors performed a population-based analysis of national trends, costs, and outcomes associated with cervical spondylotic myelopathy (CSM) in the United States. They assessed postoperative complications, resource utilization, and predictors of costs, in this surgically treated CSM population. METHODS MarketScan data (2006-2010) were used to retrospectively analyze the complications and costs of different spine surgeries for CSM. The authors determined outcomes following anterior cervical discectomy and fusion (ACDF), posterior fusion, combined anterior/posterior fusion, and laminoplasty procedures. RESULTS The authors identified 35,962 CSM patients, comprising 5154 elderly (age ≥ 65 years) patients (mean 72.2 years, 54.9% male) and 30,808 nonelderly patients (mean 51.1 years, 49.3% male). They found an overall complication rate of 15.6% after ACDF, 29.2% after posterior fusion, 41.1% after combined anterior and posterior fusion, and 22.4% after laminoplasty. Following ACDF and posterior fusion, a significantly higher risk of complication was seen in the elderly compared with the nonelderly (reference group). The fusion level and comorbidity-adjusted ORs with 95% CIs for these groups were 1.54 (1.40-1.68) and 1.25 (1.06-1.46), respectively. In contrast, the elderly population had lower 30-day readmission rates in all 4 surgical cohorts (ACDF, 2.6%; posterior fusion, 5.3%; anterior/posterior fusion, 3.4%; and laminoplasty, 3.6%). The fusion level and comorbidity-adjusted odds ratios for 30-day readmissions for ACDF, posterior fusion, combined anterior and posterior fusion, and laminoplasty were 0.54 (0.44-0.68), 0.32 (0.24-0.44), 0.17 (0.08-0.38), and 0.39 (0.18-0.85), respectively. CONCLUSIONS The authors' analysis of the MarketScan database suggests a higher complication rate in the surgical treatment of CSM than previous national estimates. They found that elderly age (≥ 65 years) significantly increased complication risk following ACDF and posterior fusion. Elderly patients were less likely to experience a readmission within 30 days of surgery. Postoperative complication occurrence, and 30-day readmission were significant drivers of total cost within 90 days of the index surgical procedure.

    View details for DOI 10.3171/2016.3.FOCUS1669

    View details for PubMedID 27246481

  • Performance Measures in Neurosurgical Patient Care Differing Applications of Patient Safety Indicators MEDICAL CARE Moghavem, N., McDonald, K., Ratliff, J. K., Hernandez-Boussard, T. 2016; 54 (4): 359-364


    Patient Safety Indicators (PSIs) are administratively coded identifiers of potentially preventable adverse events. These indicators are used for multiple purposes, including benchmarking and quality improvement efforts. Baseline PSI evaluation in high-risk surgeries is fundamental to both purposes.Determine PSI rates and their impact on other outcomes in patients undergoing cranial neurosurgery compared with other surgeries.The Agency for Healthcare Research and Quality (AHRQ) PSI software was used to flag adverse events and determine risk-adjusted rates (RAR). Regression models were built to assess the association between PSIs and important patient outcomes.We identified cranial neurosurgeries based on International Classification of Diseases, Ninth Revision, Clinical Modification codes in California, Florida, New York, Arkansas, and Mississippi State Inpatient Databases, AHRQ, 2010-2011.PSI development, 30-day all-cause readmission, length of stay, hospital costs, and inpatient mortality.A total of 48,424 neurosurgical patients were identified. Procedure indication was strongly associated with PSI development. The neurosurgical population had significantly higher RAR of most PSIs evaluated compared with other surgical patients. Development of a PSI was strongly associated with increased length of stay and hospital cost and, in certain PSIs, increased inpatient mortality and 30-day readmission.In this population-based study, certain accountability measures proposed for use as value-based payment modifiers show higher RAR in neurosurgery patients compared with other surgical patients and were subsequently associated with poor outcomes. Our results indicate that for quality improvement efforts, the current AHRQ risk-adjustment models should be viewed in clinically meaningful stratified subgroups: for profiling and pay-for-performance applications, additional factors should be included in the risk-adjustment models. Further evaluation of PSIs in additional high-risk surgeries is needed to better inform the use of these metrics.

    View details for DOI 10.1097/MLR.0000000000000490

    View details for Web of Science ID 000372935200004

    View details for PubMedID 26759981

  • Piriformis Syndrome With Variant Sciatic Nerve Anatomy: A Case Report. PM & R : the journal of injury, function, and rehabilitation Kraus, E., Tenforde, A. S., Beaulieu, C. F., Ratliff, J., Fredericson, M. 2016; 8 (2): 176-179


    A 68-year-old male long distance runner presented with low back and left buttock pain, which eventually progressed to severe and debilitating pain, intermittently radiating to the posterior thigh and foot. A comprehensive workup ruled out possible spine or hip causes of his symptoms. A pelvic magnetic resonance imaging neurogram with complex oblique planes through the piriformis demonstrated variant anatomy of the left sciatic nerve consistent with the clinical diagnosis of piriformis syndrome. The patient ultimately underwent neurolysis with release of the sciatic nerve and partial resection of the piriformis muscle. After surgery the patient reported significant pain reduction and resumed running 3 months later. Piriformis syndrome is uncommon but should be considered in the differential diagnosis for buttock pain. Advanced imaging was essential to guide management.

    View details for DOI 10.1016/j.pmrj.2015.09.005

    View details for PubMedID 26377629

  • Postoperative Visual Loss Following Lumbar Spine Surgery: A Review of Risk Factors by Diagnosis WORLD NEUROSURGERY Li, A., Swinney, C., Veeravagu, A., Bhatti, I., Ratliff, J. 2015; 84 (6): 2010-2021
  • Craniotomy for Resection of Meningioma: An Age-Stratified Analysis of the MarketScan Longitudinal Database WORLD NEUROSURGERY Connolly, I. D., Cole, T., Veeravagu, A., Popat, R., Ratliff, J., Li, G. 2015; 84 (6): 1864-1870


    We sought to describe complications following resection for meningioma utilizing longitudinal administrative data, which our group has recently shown to be superior to nonlongitudinal administrative data.We identified patients who underwent resection for meningioma between 2010-2012 in the Thomson Reuters MarketScan database. Current procedural terminology (CPT) coding at inpatient visit was used to select for meningioma resection procedure. Comorbidities and complications were obtained using International Classification of Disease version 9 (ICD-9) or CPT coding. Associations between complications and demographic and clinical factors were evaluated with logistic regression.We identified a total of 2216 patients. Approximately 41% developed one or more perioperative complications. Approximately 15% were readmitted within thirty days of their procedure. The most frequent complications that occurred in our cohort were new post-operative seizures (11.8%), post-operative dysrhythmia (7.9%), intracranial hemorrhage (5.9%), and cerebral artery occlusion (5.4%). General neurosurgical complications and general neurological complications occurred in 4.4 % and 16.1 % of patients respectively. Nearly 55% of elderly patients (≥ 70 years) developed one or more perioperative complication (vs. 39% of nonelderly patients). After adjusting for comorbidities, elderly status and male gender were found to be significantly associated with increased odds for a variety of complications.In this study, we report complication rates in patients undergoing resection for meningioma. Due to the longitudinal nature of the MarketScan database, we were able to capture a wide array of specific post-operative complications associated with meningioma resection procedures. Care should be taken in the selection of candidates for meningioma resection.

    View details for DOI 10.1016/j.wneu.2015.08.018

    View details for Web of Science ID 000366286300065

    View details for PubMedID 26318633

  • Clavicle pain and reduction of incisional and fascial pain after posterior cervical surgery JOURNAL OF NEUROSURGERY-SPINE Duetzmann, S., Cole, T., Senft, C., Seifert, V., Ratliff, J. K., Park, J. 2015; 23 (6): 684-689
  • Improved capture of adverse events after spinal surgery procedures with a longitudinal administrative database JOURNAL OF NEUROSURGERY-SPINE Veeravagu, A., Cole, T. S., Azad, T. D., Ratliff, J. K. 2015; 23 (3): 374-382
  • Cervical laminoplasty developments and trends, 2003-2013: a systematic review. Journal of neurosurgery. Spine Duetzmann, S., Cole, T., Ratliff, J. K. 2015; 23 (1): 24-34


    OBJECT Despite extensive clinical experience with laminoplasty, the efficacy of the procedure and its advantages over laminectomy remain unclear. Specific clinical elements, such as incidence or progression of kyphosis, incidence of axial neck pain, postoperative cervical range of motion, and incidence of postoperative C-5 palsies, are of concern. The authors sought to comprehensively review the laminoplasty literature over the past 10 years while focusing on these clinical elements. METHODS The authors conducted a literature search of articles in the Medline database published between 2003 and 2013, in which the terms "laminoplasty," "laminectomy," and "posterior cervical spine procedures" were used as key words. Included was every single case series in which patient outcomes after a laminoplasty procedure were reported. Excluded were studies that did not report on at least one of the above-mentioned items. RESULTS A total of 103 studies, the results of which contained at least 1 of the prespecified outcome variables, were identified. These studies reported 130 patient groups comprising 8949 patients. There were 3 prospective randomized studies, 1 prospective nonrandomized alternating study, 15 prospective nonrandomized data collections, and 84 retrospective reviews. The review revealed a trend for the use of miniplates or hydroxyapatite spacers on the open side in Hirabayashi-type laminoplasty or on the open side in a Kurokawa-type laminoplasty. Japanese Orthopaedic Association (JOA) scoring was reported most commonly; in the 4949 patients for whom a JOA score was reported, there was improvement from a mean (± SD) score of 9.91 (± 1.65) to a score of 13.68 (± 1.05) after a mean follow-up of 44.18 months (± 35.1 months). The mean preoperative and postoperative C2-7 angles (available for 2470 patients) remained stable from 14.17° (± 0.19°) to 13.98° (± 0.19°) of lordosis (average follow-up 39 months). The authors found significantly decreased kyphosis when muscle/posterior element-sparing techniques were used (p = 0.02). The use of hardware in the form of hydroxyapatite spacers or miniplates did not influence the progression of deformity (p = 0.889). An overall mean (calculated from 2390 patients) of 47.3% loss of range of motion was reported. For the studies that used a visual analog scale score (totaling 986 patients), the mean (cohort size-adjusted) postoperative pain level at a mean follow-up of 29 months was 2.78. For the studies that used percentages of patients who complained of postoperative axial neck pain (totaling 1249 patients), the mean patient number-adjusted percentage was 30% at a mean follow-up of 51 months. The authors found that 16% of the studies that were published in the last 10 years reported a C-5 palsy rate of more than 10% (534 patients), 41% of the studies reported a rate of 5%-10% (n = 1006), 23% of the studies reported a rate of 1%-5% (n = 857), and 12.5% reported a rate of 0% (n = 168). CONCLUSIONS Laminoplasty remains a valid option for decompression of the spinal cord. An understanding of the importance of the muscle-ligament complex, plus the introduction of hardware, has led to progress in this type of surgery. Reporting of outcome metrics remains variable, which makes comparisons among the techniques difficult.

    View details for DOI 10.3171/2014.11.SPINE14427

    View details for PubMedID 25909270

  • Sacral Peak Pressure in Healthy Volunteers and Patients With Spinal Cord Injury With and Without Liquid-Based Pad NURSING RESEARCH Duetzmann, S., Forsey, L. M., Senft, C., Seifert, V., Ratliff, J., Park, J. 2015; 64 (4): 300-305
  • Anterior Versus Posterior Approach for Multilevel Degenerative Cervical Disease A Retrospective Propensity Score-Matched Study of the MarketScan Database SPINE Cole, T., Veeravagu, A., Zhang, M., Azad, T. D., Desai, A., Ratliff, J. K. 2015; 40 (13): 1033-1038
  • Cranial neurosurgical 30-day readmissions by clinical indication JOURNAL OF NEUROSURGERY Moghavem, N., Morrison, D., Ratliff, J. K., Hernandez-Boussard, T. 2015; 123 (1): 189-197


    OBJECT Postsurgical readmissions are common and vary by procedure. They are significant drivers of increased expenditures in the health care system. Reducing readmissions is a national priority that has summoned significant effort and resources. Before the impact of quality improvement efforts can be measured, baseline procedure-related 30-day all-cause readmission rates are needed. The objects of this study were to determine population-level, 30-day, all-cause readmission rates for cranial neurosurgery and identify factors associated with readmission. METHODS The authors identified patient discharge records for cranial neurosurgery and their 30-day all-cause readmissions using the Agency for Healthcare Research and Quality (AHRQ) State Inpatient Databases for California, Florida, and New York. Patients were categorized into 4 groups representing procedure indication based on ICD-9-CM diagnosis codes. Logistic regression models were developed to identify patient characteristics associated with readmissions. The main outcome measure was unplanned inpatient admission within 30 days of discharge. RESULTS A total of 43,356 patients underwent cranial neurosurgery for neoplasm (44.23%), seizure (2.80%), vascular conditions (26.04%), and trauma (26.93%). Inpatient mortality was highest for vascular admissions (19.30%) and lowest for neoplasm admissions (1.87%; p < 0.001). Thirty-day readmissions were 17.27% for the neoplasm group, 13.89% for the seizure group, 23.89% for the vascular group, and 19.82% for the trauma group (p < 0.001). Significant predictors of 30-day readmission for neoplasm were Medicaid payer (OR 1.33, 95% CI 1.15-1.54) and fluid/electrolyte disorder (OR 1.44, 95% CI 1.29-1.62); for seizure, male sex (OR 1.74, 95% CI 1.17-2.60) and index admission through the emergency department (OR 2.22, 95% CI 1.45-3.43); for vascular, Medicare payer (OR 1.21, 95% CI 1.05-1.39) and renal failure (OR 1.52, 95% CI 1.29-1.80); and for trauma, congestive heart failure (OR 1.44, 95% CI 1.16-1.80) and coagulopathy (OR 1.51, 95% CI 1.25-1.84). Many readmissions had primary diagnoses identified by the AHRQ as potentially preventable. CONCLUSIONS The frequency of 30-day readmission rates for patients undergoing cranial neurosurgery varied by diagnosis between 14% and 24%. Important patient characteristics and comorbidities that were associated with an increased readmission risk were identified. Some hospital-level characteristics appeared to be associated with a decreased readmission risk. These baseline readmission rates can be used to inform future efforts in quality improvement and readmission reduction.

    View details for DOI 10.3171/2014.12.JNS14447

    View details for Web of Science ID 000356981200025

  • International classification of disease clinical modification 9 modeling of a patient comorbidity score predicts incidence of perioperative complications in a nationwide inpatient sample assessment of complications in spine surgery. Journal of spinal disorders & techniques Chitale, R., Campbell, P. G., Yadla, S., Whitmore, R. G., Maltenfort, M. G., Ratliff, J. K. 2015; 28 (4): 126-133


    SUMMARY OF BACKGROUND DATA:: A patient comorbidity score (RCS) was developed from a prospective study of complications occurring in spine surgery patients. OBJECTIVE:: To validate the RCS, we present an ICD-CM-9 model of the score and correlate the score with complication incidence in a group of patients from the Nationwide Inpatient Sample (NIS) database. We compare the predictive value of the score to the Charlson index. STUDY DESIGN:: We conducted a retrospective assessment of NIS patients undergoing cervical or thoracolumbar spine surgery for degenerative pathology from 2002 to 2009. METHODS:: We generated an ICD-9-CM coding-based model of our prospectively derived RCS, categorizing diagnostic codes to represent relevant comorbidities. Multivariate models were performed to eliminate the least significant variables. ICD-9-CM coding was also used to calculate a Charlson comorbidity score for each patient. The accuracy of the RCS was compared with the Charlson index through use of a receiver operating curve (ROC). RESULTS:: A total of 352,535 patients undergoing 369,454 spine procedures for degenerative disease were gathered. Hypertension and hyperlipidemia were the most common comorbidities. Cervical procedures resulted in 8286 complications (4.50%) while thoracolumbar procedures produced 25,118 complications (13.55%). Increasing RCS correlated linearly with increasing complication incidence (OR 1.11, 95% CI 1.10-1.13, P<0.0001). Logistic regression revealed that neurological deficit, cardiac conditions, and drug or alcohol use had greatest association with complication occurrence. The Charlson index also correlated with complication occurrence in both cervical (OR 1.25, 95% CI 1.23-1.27) and thoracolumbar (1.11, 95% CI 1.10-1.12) patient groups. ROC analysis allowed a comparison of accuracy of the indices by comparing predictive values. The RCS performed as well as the Charlson index in predicting complication occurrence in both cervical and thoracic spine patients. CONCLUSIONS:: ICD-9 based modeling validated that RCS correlates with complication occurrence. The RCS performed as well as the Charlson index in predicting risk of complication in spine patients.

    View details for DOI 10.1097/BSD.0b013e318270dad7

    View details for PubMedID 22960417

  • Letter. Spine Cole, T., Ratliff, J. 2015; 40 (9): 668-?

    View details for DOI 10.1097/BRS.0000000000000858

    View details for PubMedID 26030219

  • National Trends in Burn and Inhalation Injury in Burn Patients: Results of Analysis of the Nationwide Inpatient Sample Database JOURNAL OF BURN CARE & RESEARCH Veeravagu, A., Yoon, B. C., Jiang, B., Carvalho, C. M., Rincon, F., Maltenfort, M., Jallo, J., Ratliff, J. K. 2015; 36 (2): 258-265


    The aim of this study was describe national trends in prevalence, demographics, hospital length of stay (LOS), hospital charges, and mortality for burn patients with and without inhalational injury and to compare to the National Burn Repository. Burns and inhalation injury cause considerable mortality and morbidity in the United States. There remains insufficient reporting of the demographics and outcomes surrounding such injuries. The National Inpatient Sample database, the nation's largest all-payer inpatient care data repository, was utilized to select 506,628 admissions for burns from 1988 to 2008 based on ICD-9-CM recording. The data were stratified based on the extent of injury (%TBSA) and presence or absence of inhalational injury. Inhalation injury was observed in only 2.2% of burns with <20% TBSA but 14% of burns with 80 to 99% TBSA. Burn patients with inhalation injury were more likely to expire in-hospital compared to those without (odds ratio, 3.6; 95% confidence interval, 2.7-5.0; P < .001). Other factors associated with higher mortality were African-American race, female sex, and urban practice setting. Patients treated at rural facilities and patients with hyperglycemia had lower mortality rates. Each increase in percent of TBSA of burns increased LOS by 2.5%. Patients with burns covering 50 to 59% of TBSA had the longest hospital stay at a median of 24 days (range, 17-55). The median in-hospital charge for a burn patient with inhalation injury was US$32,070, compared to US$17,600 for those without. Overall, patients who expired from burn injury accrued higher in-hospital charges (median, US$50,690 vs US$17,510). Geographically, California and New Jersey were the states with the highest charges, whereas Vermont and Maryland were states with the lowest charges. The study analysis provides a broad sampling of nationwide demographics, LOS, and in-hospital charges for patients with burns and inhalation injury.

    View details for DOI 10.1097/BCR.0000000000000064

    View details for Web of Science ID 000350395100020

  • Adding insult to injury: discontinuous insurance following spine trauma. journal of bone and joint surgery. American volume Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97 (2): 141-146


    Spine trauma patients may represent a group for whom insurance fails to provide protection from catastrophic medical expenses, resulting in the transfer of financial burden onto individual families and public payers. This study compares the rate of insurance discontinuation for patients who underwent surgery for traumatic spine injury with and without spinal cord injury with the rate for matched control subjects.We used the MarketScan database to perform a retrospective cohort study of privately insured spine trauma patients who underwent surgery from 2006 to 2010. Kaplan-Meier survival analysis was used to assess the time to insurance discontinuation. Cox proportional-hazards regression was used to determine hazard ratios for insurance discontinuation among spine trauma patients compared with the matched control population.The median duration of existing insurance coverage was 20.2 months for those with traumatic spinal cord injury, 25.6 months for those with traumatic spine injury without spinal cord injury, and 48.0 months for the matched control cohort (log-rank p < 0.0001). After controlling for multiple covariates, the hazard ratios for discontinuation of insurance were 2.02 (95% CI [confidence interval], 1.83 to 2.23) and 2.78 (95% CI, 2.31 to 3.35) for the trauma patients without and with spinal cord injury, respectively, compared with matched controls.Rates of insurance discontinuation are significantly higher for trauma patients with severe spine injury compared with the uninjured population, indicating that patients with disabling injuries are at increased risk for loss of insurance coverage.

    View details for DOI 10.2106/JBJS.N.00148

    View details for PubMedID 25609441

  • Adding Insult to Injury: Discontinuous Insurance Following Spine Trauma JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Kastenberg, Z. J., Hurley, M. P., Weiser, T. G., Cole, T. S., Staudenmayer, K. L., Spain, D. A., Ratliff, J. K. 2015; 97A (2): 141-146
  • Retrosigmoid Versus Translabyrinthine Approach for Acoustic Neuroma Resection: An Assessment of Complications and Payments in a Longitudinal Administrative Database. Cure¯us Cole, T., Veeravagu, A., Zhang, M., Azad, T., Swinney, C., Li, G. H., Ratliff, J. K., Giannotta, S. L. 2015; 7 (10)


    Object Retrosigmoid (RS) and translabyrinthine (TL) surgery remain essential treatment approaches for symptomatic or enlarging acoustic neuromas (ANs). We compared nationwide complication rates and payments, independent of tumor characteristics, for these two strategies. Methods We identified 346 and 130 patients who underwent RS and TL approaches, respectively, for AN resection in the 2010-2012 MarketScan database, which characterizes primarily privately-insured patients from multiple institutions nationwide. Results Although we found no difference in 30-day general neurological or neurosurgical complication rates, in TL procedures there was a decreased risk for postoperative cranial nerve (CN) VII injury (20.2% vs 10.0%, CI 0.23-0.82), dysphagia (10.4% vs 3.1%, CI 0.10-0.78), and dysrhythmia (8.4% vs 2.3%, CI 0.08-0.86). Overall, there was no difference in surgical repair rates of CSF leak; however, intraoperative fat grafting was significantly higher in TL approaches (19.8% vs 60.2%, CI 3.95-9.43). In patients receiving grafts, there was a trend towards a higher repair rate after RS approach, while in those without grafts, there was a trend towards a higher repair rate after TL approach. Median total payments were $16,856 higher after RS approaches ($67,774 vs $50,918, p < 0.0001), without differences in physician or 90-day postoperative payments. Conclusions  Using a nationwide longitudinal database, we observed that the TL, compared to RS, approach for AN resection experienced lower risks of CN VII injury, dysphagia, and dysrhythmia. There was no significant difference in CSF leak repair rates. The payments for RS procedures exceed payments for TL procedures by approximately $17,000. Data from additional years and non-private sources will further clarify these trends.

    View details for DOI 10.7759/cureus.369

    View details for PubMedID 26623224

  • The use of bone morphogenetic protein in thoracolumbar spine procedures: analysis of the MarketScan longitudinal database SPINE JOURNAL Veeravagu, A., Cole, T. S., Jiang, B., Ratliff, J. K., Gidwani, R. A. 2014; 14 (12): 2929-2937
  • The Prevalence and Impact of Mortality of the Acute Respiratory Distress Syndrome on Admissions of Patients With Ischemic Stroke in the United States JOURNAL OF INTENSIVE CARE MEDICINE Rincon, F., Maltenfort, M., Dey, S., Ghosh, S., Vibbert, M., Urtecho, J., Jallo, J., Ratliff, J. K., McBride, J. W., Bell, R. 2014; 29 (6): 357-364
  • Usage of Recombinant Human Bone Morphogenetic Protein in Cervical Spine Procedures JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Cole, T., Veeravagu, A., Jiang, B., Ratliff, J. K. 2014; 96A (17): 1409-1416
  • Longitudinal incidence and concurrence rates for traumatic brain injury and spine injury - A twenty year analysis CLINICAL NEUROLOGY AND NEUROSURGERY Ghobrial, G. M., Amenta, P. S., Maltenfort, M., Williams, K. A., Harrop, J. S., Sharan, A., Jallo, J., Heller, J., Ratliff, J., Prasad, S. 2014; 123: 174-180


    The reported incidence of concurrent traumatic brain (TBI) and spine or spinal cord injuries (SCI) is poorly defined, with widely variable literature rates from 16 to 74%.To define the incidence of concurrent TBI and SCI, and compare the incidence over a twenty-year time period.To define the longitudinal incidence and concurrent rate of TBI and SCI via a retrospective review of the Nationwide Inpatient Sample (NIS) database over a twenty year period.Over the study period, the incidence of TBI declined from 143 patients/100k admissions to 95 patients/100k. However, there was a concurrent increase in SCI from 61 patients/100k admissions to 75 patients/100k admissions (P<0.0001). Regional variations in SCI trends were noted, with specific regions demonstrating an increasing trend. Cervical fractures had the greatest increase by nearly a three-fold rise (1988: 4562-2008: 12,418). There was an increase in the incidence of TBI among SCI admission from 3.7% (1988) to 12.5% (2008) (OR=1.067 per year; 95% CI=1.065-1.069 per year; P<0.0001). Concurrently, SCI patients had an increase in TBI (9.1% (1988)-15.9% (2008) (OR=1.038 per year (95% CI 1.036-1.040; P<0.001))).A retrospective review of the NIS demonstrates a rising trend in the incidence of concurrent TBI and SCI. More investigative work is necessary to examine causative factors for this trend.

    View details for DOI 10.1016/j.clineuro.2014.05.013

    View details for Web of Science ID 000339989100032

    View details for PubMedID 24973569

  • Gender differences in compensation in academic medicine: the results from four neurological specialties within the University of California Healthcare System SCIENTOMETRICS Henderson, M. T., Fijalkowski, N., Wang, S. K., Maltenfort, M., Zheng, L. L., Ratliff, J., Moshfeghi, A. A., Moshfeghi, D. M. 2014; 100 (1): 297-306
  • Revision rates and complication incidence in single- and multilevel anterior cervical discectomy and fusion procedures: an administrative database study SPINE JOURNAL Veeravagu, A., Cole, T., Jiang, B., Ratliff, J. K. 2014; 14 (7): 1125-1131
  • Acute Lung Injury in Patients with Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Study WORLD NEUROSURGERY Veeravagu, A., Chen, Y., Ludwig, C., Rincon, F., Maltenfort, M., Jallo, J., Choudhri, O., Steinberg, G. K., Ratliff, J. K. 2014; 82 (1-2): E235-E241
  • Minding the stroke business. World neurosurgery Gonzalez, L. F., Jabbour, P., Ratliff, J., Tjoumakaris, S., Dumont, A., Rosenwasser, R. H. 2013; 80 (3-4): 228-229

    View details for DOI 10.1016/j.wneu.2012.05.028

    View details for PubMedID 22633840

  • Acute respiratory distress syndrome and acute lung injury in patients with vertebral column fracture(s) and spinal cord injury: a nationwide inpatient sample study SPINAL CORD Veeravagu, A., Jiang, B., Rincon, F., Maltenfort, M., Jallo, J., Ratliff, J. K. 2013; 51 (6): 461-465


    Study design:Retrospective Nationwide Inpatient Sample (NIS) study.Objectives:To determine national trends in prevalence, risk factors and mortality for vertebral column fracture (VCF) and spinal cord injury (SCI) patients with and without acute respiratory distress syndrome/acute lung injury (ARDS/ALI).Setting:United States of America, 1988 to 2008.Methods:The NIS was utilized to select 284 612 admissions for VCF with and without acute SCI from 1988 to 2008 based on ICD-9-CM. The data were stratified for in-hospital complications of ARDS/ALI.Results:Patients with SCI were more likely to develop ARDS/ALI compared with those without (odds ratio (OR): 4.9, 95% confidence interval (CI) 4.7-5.2, P<0.001). Compared with patients with lumbar fractures, those with cervical, thoracic and sacral fractures were more likely to develop ARDS/ALI (P<0.001). ARDS/ALI was statistically more prevalent (P<0.01) in VCF/SCI patients with epilepsy, sepsis, cardiac arrest, congestive heart failure (CHF), hypertension, chronic obstructive pulmonary disease and metabolic disorders. Patients with female gender, surgery at rural practice setting, and coronary artery disease and diabetes were less likely to develop ARDS/ALI (P<0.001). VCF/SCI patients who developed ARDS/ALI were more likely to die in-hospital than those without ARDS/ALI (OR 6.5, 95% CI 6.0-7.1, P<0.001). Predictors of in-hospital mortality after VCF/SCI include: older age, male sex, epilepsy, sepsis, hypertension, CHF, chronic obstructive pulmonary disease and liver disease. Patients who developed ARDS/ALI stayed a mean of 25 hospital days (30-440 days) while patients without ARDS/ALI stayed a mean of 6 days (7-868 days, P<0.001).Conclusion:Our analysis demonstrates that SCI patients are more at risk for ARDS/ALI, which carries a significantly higher risk of mortality.Spinal Cord advance online publication, 12 March 2013; doi:10.1038/sc.2013.16.

    View details for DOI 10.1038/sc.2013.16

    View details for Web of Science ID 000320224100007

    View details for PubMedID 23478670

  • Considering the diagnosis of occipitocervical dissociation. spine journal Kalani, M. A., Ratliff, J. K. 2013; 13 (5): 520-522


    COMMENTARY ON: Gire JD, Roberto RF, Bobinski M, et al. The utility and accuracy of computed tomography in the diagnosis of occipitocervical dissociation. Spine J 2013;13:510-9 (in this issue).

    View details for DOI 10.1016/j.spinee.2013.02.030

    View details for PubMedID 23664556

  • A biologic without guidelines: the YODA project and the future of bone morphogenetic protein-2 research SPINE JOURNAL Carragee, E. J., Baker, R. M., Benzel, E. C., Bigos, S. J., Cheng, I., Corbin, T. P., Deyo, R. A., Hurwitz, E. L., Jarvik, J. G., Kang, J. D., Lurie, J. D., Mroz, T. E., Oener, F. C., Peul, W. C., Rainville, J., Ratliff, J. K., Rihn, J. A., Rothman, D. J., Schoene, M. L., Spengler, D. M., Weiner, B. K. 2012; 12 (10): 877-880

    View details for DOI 10.1016/j.spinee.2012.11.002

    View details for Web of Science ID 000311684600004

    View details for PubMedID 23199819

  • Impact of Acute Lung Injury and Acute Respiratory Distress Syndrome After Traumatic Brain Injury in the United States NEUROSURGERY Rincon, F., Ghosh, S., Dey, S., Maltenfort, M., Vibbert, M., Urtecho, J., McBride, W., Moussouttas, M., Bell, R., Ratliff, J. K., Jallo, J. 2012; 71 (4): 795-803


    Traumatic brain injury (TBI) is a major cause of disability, morbidity, and mortality. The effect of the acute respiratory distress syndrome and acute lung injury (ARDS/ALI) on in-hospital mortality after TBI remains controversial.To determine the epidemiology of ARDS/ALI, the prevalence of risk factors, and impact on in-hospital mortality after TBI in the United States.Retrospective cohort study of admissions of adult patients>18 years with a diagnosis of TBI and ARDS/ALI from 1988 to 2008 identified through the Nationwide Inpatient Sample.During the 20-year study period, the prevalence of ARDS/ALI increased from 2% (95% confidence interval [CI], 2.1%-2.4%) in 1988 to 22% (95% CI, 21%-22%) in 2008 (P<.001). ARDS/ALI was more common in younger age; males; white race; later year of admission; in conjunction with comorbidities such as congestive heart failure, hypertension, chronic obstructive pulmonary disease, chronic renal and liver failure, sepsis, multiorgan dysfunction; and nonrural, medium/large hospitals, located in the Midwest, South, and West continental US location. Mortality after TBI decreased from 13% (95% CI, 12%-14%) in 1988 to 9% (95% CI, 9%-10%) in 2008 (P<.001). ARDS/ALI-related mortality after TBI decreased from 33% (95% CI, 33%-34%) in 1988 to 28% (95% CI, 28%-29%) in 2008 (P<.001). Predictors of in-hospital mortality after TBI were older age, male sex, white race, cancer, chronic kidney disease, hypertension, chronic liver disease, congestive heart failure, ARDS/ALI, and organ dysfunctions.Our analysis demonstrates that ARDS/ALI is common after TBI. Despite an overall reduction of in-hospital mortality, ARDS/ALI carries a higher risk of in-hospital death after TBI.

    View details for DOI 10.1227/NEU.0b013e3182672ae5

    View details for Web of Science ID 000309117200027

    View details for PubMedID 22855028

  • The incidence of pulmonary embolism (PE) after spinal fusions CLINICAL NEUROLOGY AND NEUROSURGERY Senders, Z. J., Zussman, B. M., Maltenfort, M. G., Sharan, A. D., Ratliff, J. K., Harrop, J. S. 2012; 114 (7): 897-901


    Pulmonary embolism (PE) is a rare but serious event that may occur after spinal surgery.To correlate PE incidence after spinal arthrodesis with surgical approach, region of spine operated, and primary spinal pathology. To identify PE incidence trends in this population.The Nationwide Inpatient Sample was queried using ICD-9 codes (81.01-81.08) for spinal fusion procedures over a 21-year period (1988-2008). Other data points included PE occurrence, surgical approach, spinal region, surgical indication, and mortality. Multivariate and relational analyses were performed.4,505,556 patients were identified and 9530 had PE (incidence=0.2%). PE patients had higher odds of combined A/P surgical approaches than posterior approaches (OR=1.97; 95% CI=1.66-2.33), and PE incidence was higher in thoracic versus cervical or lumbar fusions (OR=2.54; 95% CI=2.14-3.02). PE was more likely with vertebral fracture (OR=1.85; 95% CI=1.53-2.23) and SCI with vertebral fracture (OR=4.59; 95% CI=3.72-5.70) than without trauma. Between 1988 and 2008, the PE incidence remained stable for patients with intervertebral disk degeneration and scoliosis, but increased for patients with vertebral fracture, and SCI with vertebral fracture. There was greater inpatient mortality with occurrence of a PE (OR=12.92; 95% CI=10.55-14.41).Although the incidence of PE in spinal arthrodesis patients is only 0.2%, there is a higher incidence after combined A/P approaches, thoracic procedures, and trauma surgical procedures. Despite the overall PE incidence remaining stable since 1988, incidence steadily increased among trauma patients. Further research is needed to explain these trends, given the context of changing patient populations and improving surgical techniques and prophylaxis measures. Greater caution and prophylaxis among trauma patients may be warranted.

    View details for DOI 10.1016/j.clineuro.2012.01.044

    View details for Web of Science ID 000307855800013

    View details for PubMedID 22386262

  • Anatomical relationships of the anterior blood vessels to the lower lumbar intervertebral discs: analysis based on magnetic resonance imaging of patients in the prone position. journal of bone and joint surgery. American volume Vaccaro, A. R., Kepler, C. K., Rihn, J. A., Suzuki, H., Ratliff, J. K., Harrop, J. S., Morrison, W. B., Limthongkul, W., Albert, T. J. 2012; 94 (12): 1088-1094


    Intra-abdominal vascular injuries are rare during posterior lumbar spinal surgery, but they can result in major morbidity or mortality when they do occur. We are aware of no prior studies that have used prone patient positioning during magnetic resonance imaging for the purpose of characterizing the retroperitoneal iliac vasculature with respect to the intervertebral disc. The purpose of this study was to define the vascular anatomy adjacent to the lower lumbar spine with use of supine and prone magnetic resonance imaging.A prospective observational study included thirty patients without spinal abnormality who underwent supine and prone magnetic resonance imaging without abdominal compression. The spinal levels of the aortic bifurcation and confluence of the common iliac veins were identified. The proximity of the anterior iliac vessels to the anterior and posterior aspects of the anulus fibrosus in sagittal and coronal planes was measured by two observers, and interobserver reliability was calculated.The aortic bifurcation and confluence of the common iliac veins were most commonly at the level of the L4 vertebral body and migrated cranially with prone positioning. The common iliac vessels were closer to the anterior aspect of the intervertebral disc and to the midline at L4-L5 as compared with L5-S1, consistent with the bifurcation at the L4 vertebral body. Prone positioning resulted in greater distances between the disc and iliac vessels at L4-L5 and L5-S1 by an average of 3 mm. The position of the anterior aspect of the anulus with respect to each iliac vessel demonstrated substantial variation between subjects. The intraclass correlation coefficient for measurement of vessel position exceeded 0.9, demonstrating excellent interobserver reliability.This study confirmed the L4 level of the aortic bifurcation and iliac vein coalescence but also demonstrated substantial mobility of the great vessels with positioning. Supine magnetic resonance imaging will underestimate the proximity of the vessels to the intervertebral disc. Large interindividual variation in the location of vasculature was noted, emphasizing the importance of careful study of the location of the retroperitoneal vessels on a case-by-case basis.

    View details for DOI 10.2106/JBJS.K.00671

    View details for PubMedID 22717827

  • Anatomical Relationships of the Anterior Blood Vessels to the Lower Lumbar Intervertebral Discs Analysis Based on Magnetic Resonance Imaging of Patients in the Prone Position JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Vaccaro, A. R., Kepler, C. K., Rihn, J. A., Suzuki, H., Ratliff, J. K., Harrop, J. S., Morrison, W. B., Limthongkul, W., Albert, T. J. 2012; 94A (12): 1088-1094
  • Patient Comorbidities and Complications After Spinal Surgery A Societal-Based Cost Analysis SPINE Whitmore, R. G., Stephen, J., Stein, S. C., Campbell, P. G., Yadla, S., Harrop, J. S., Sharan, A. D., Maltenfort, M. G., Ratliff, J. K. 2012; 37 (12): 1065-1071


    Prospective observational study.To determine how patient comorbidities and perioperative complications after spinal surgery affect the health care costs to society.Despite efforts to reduce adverse events related to spinal surgery, complications are common and significantly increased by patient comorbidities.Patients who underwent spinal surgery at a tertiary academic center during a 6-month period (May 2008 to December 2008) were prospectively followed. All demographic data, comorbidities, procedural information, and complications to 30-day follow-up were recorded. Diagnosis-Related Group codes and Current Procedural Terminology codes were captured for each patient. Direct costs were estimated from a societal perspective, using 2008 Medicare rates of reimbursement. A multivariable analysis was performed to assess the impact of specific patient comorbidities and complications on total health care costs.A total of 226 cases were analyzed. The mean cost of care for cases with complications was greater than that for cases without complications ($13,518.35 [95% confidence interval (CI), $9378.80-$17,657.90]; P < 0.0001). These results were consistent across degenerative, traumatic, and tumor/infection preoperative diagnoses. Cases with major complications were more costly than those with minor complications ($13,714.88 [CI, $6353.02-$21,076.74]; P = 0.0001). Systemic malignancy and preoperative neurological comorbidity were each associated with an increase in the cost of care ($7919 [CI, $2073-$15,225]; P = 0.006] and $5508 [CI, $814-$11,198; P = 0.02]), respectively, when compared with a baseline cost of care derived from all cases in the database. The cost of care was increased by pulmonary complications ($7233 [CI, $3982.53-$11,152.88]; P < 0.0001), instrumentation malposition ($6968 [CI, $1705.90-$14,277.16]; P = 0.0062), new neurological deficit ($4537 [CI, $863.95-$9274.30]; P = 0.013), and by wound infection ($4067 [CI, $1682.79-$6872.39]; P = 0.0004), after adjustment for covariates.Both minor and major complications were found to increase the cost of care in a prospective assessment of spine surgery complications. Specific patient comorbidities and perioperative complications are associated with significant increases in the total cost of care to society.

    View details for DOI 10.1097/BRS.0b013e31823da22d

    View details for Web of Science ID 000304364800019

    View details for PubMedID 22045005

  • The influence of medical school and residency training program upon choice of an academic career and academic productivity among otolaryngology faculty in the United States of America: Our experience of 1433 academic otolaryngologists CLINICAL OTOLARYNGOLOGY Leng, T., Jaben, K. A., Zheng, L., Yang, J., Paulus, Y. M., Moshfeghi, A. A., Maltenfort, M. G., Campbell, P. G., Ratliff, J. K., Moshfeghi, D. M. 2012; 37 (1): 58-62
  • Complications related to instrumentation in spine surgery: a prospective analysis NEUROSURGICAL FOCUS Campbell, P. G., Yadla, S., Malone, J., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2011; 31 (4)


    Prospective examination of perioperative complications in spine surgery is limited in the literature. The authors prospectively collected data on patients who underwent spinal fusion at a tertiary care center and evaluated the effect of spinal fusion and comorbidities on perioperative complications.Between May and December 2008 data were collected prospectively in 248 patients admitted to the authors' institution for spine surgery. The 202 patients undergoing spine surgery with instrumentation were further analyzed in this report. Perioperative complications occurring within the initial 30 days after surgery were included. All adverse occurrences, whether directly related to surgery, were included in the analysis.Overall, 114 (56.4%) of 202 patients experienced at least one perioperative complication. Instrumented fusions were associated with more minor complications (p = 0.001) and more overall complications (0.0024). Furthermore, in the thoracic and lumbar spine, complications increased based on the number of levels fused. Advanced patient age and certain comorbidities such as diabetes, cardiac disease, or a history of malignancy were also associated with an increased incidence of complications.Using a prospective methodology with a broad definition of complications, the authors report a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.

    View details for DOI 10.3171/2011.7.FOCUS1134

    View details for Web of Science ID 000295406500011

    View details for PubMedID 21961854

  • Medical school and residency influence on choice of an academic career and academic productivity among neurosurgery faculty in the United States Clinical article JOURNAL OF NEUROSURGERY Campbell, P. G., Awe, O. O., Maltenfort, M. G., Moshfeghi, D. M., Leng, T., Moshfeghi, A. A., Ratliff, J. K. 2011; 115 (2): 380-386


    Factors determining choice of an academic career in neurological surgery are unclear. This study seeks to evaluate the graduates of medical schools and US residency programs to determine those programs that produce a high number of graduates remaining within academic programs and the contribution of these graduates to academic neurosurgery as determined by h-index valuation.Biographical information from current faculty members of all accredited neurosurgery training programs in the US with departmental websites was obtained. Any individual who did not have an American Board of Neurological Surgery certificate (or was not board eligible) was excluded. The variables collected included medical school attended, residency program completed, and current academic rank. For each faculty member, Web of Science and Scopus h-indices were also collected.Ninety-seven academic neurosurgery departments with 986 faculty members were analyzed. All data regarding training program and medical school education were compiled and analyzed by center from which each faculty member graduated. The 20 medical schools and neurosurgical residency training programs producing the greatest number of graduates remaining in academic practice, and the respective individuals' h-indices, are reported. Medical school graduates of the Columbia University College of Physicians and Surgeons chose to enter academics the most frequently. The neurosurgery training program at the University of Pittsburgh produced the highest number of academic neurosurgeons in this sample.The use of quantitative measures to evaluate the academic productivity of medical school and residency graduates may provide objective measurements by which the subjective influence of training experiences on choice of an academic career may be inferred. The top 3 residency training programs were responsible for 10% of all academic neurosurgeons. The influence of medical school and residency experiences on choice of an academic career may be significant.

    View details for DOI 10.3171/2011.3.JNS101176

    View details for Web of Science ID 000293145100037

    View details for PubMedID 21495810

  • Medical School and Residency Influence on Choice of an Academic Career and Academic Productivity Among US Neurology Faculty ARCHIVES OF NEUROLOGY Campbell, P. G., Lee, Y. H., Bell, R. D., Maltenfort, M. G., Moshfeghi, D. M., Leng, T., Moshfeghi, A. A., Ratliff, J. K. 2011; 68 (8): 999-1004


    To evaluate the effectiveness of medical schools and neurology training programs in the United States by determining their contribution to academic neurology in terms of how many graduates choose academic careers and their respective influence on current medical knowledge through bibliometric analysis.Biographical information from current faculty members of neurology training programs in the United States was obtained through an Internet-based search of departmental Web sites. Collected variables included medical school attended, residency program completed, and current academic rank. For each faculty member, ISI Web of Science and Scopus h -indices were also collected.Data from academic neurologists from 120 training programs with 3249 faculty members were collected. All data regarding training program and medical school education were compiled and analyzed by the institution from which each individual graduated. The 20 medical schools and neurology residency training programs producing the greatest number of graduates remaining in academic practice and the mean h -indices are reported. More medical school graduates of the Columbia University College of Physicians and Surgeons chose to enter academic neurology practice than the graduates of any other institution. Analyzed by residency training program attended, New York Presbyterian Hospital (Columbia University), Mayo Clinic (Rochester, Minnesota), and Mount Sinai Medical Center (New York, New York) produced the most graduates remaining in academics.This retrospective, longitudinal cohort study examines through quantitative measures the academic productivity and rank of academic neurologists. The results demonstrate that several training programs excel in producing a significantly higher proportion of academically active neurologists.

    View details for DOI 10.1001/archneurol.2011.67

    View details for Web of Science ID 000293647500005

    View details for PubMedID 21482917

  • Preoperative Diagnosis and Early Complications in Thoracolumbar Spine Surgery A Single Center Prospective Study JOURNAL OF SPINAL DISORDERS & TECHNIQUES Yadla, S., Malone, J., Campbell, P. G., Maltenfort, M. G., Sharan, A. D., Harrop, J. S., Ratliff, J. K. 2011; 24 (2): E16-E20


    Prospective observational cohort study.To determine the incidence of early complications with thoracolumbar spine surgery and its correlation with preoperative diagnosis.The reported incidence of early complications associated with thoracolumbar surgery is highly variable. Varying definitions of what constitutes a "complication" and varying study methodologies make evaluation and comparison of the literature difficult. No large study has investigated the effect of preoperative diagnosis and patient comorbidities on early postoperative complications in thoracolumbar surgery.One-hundred twenty-eight consecutive patients who underwent thoracolumbar surgery by the neurosurgical service at the Thomas Jefferson University Hospital were prospectively entered into a central database from May to December 2008. An earlier-described, binary definition of major and minor complication was used. Data on preoperative diagnosis, comorbidities, body mass index, surgical procedure, length of stay (LOS), and early complication was examined using ? and time-to-discharge survival analysis.The overall complication incidence was 59.4%, with a minor complication incidence of 52.3% and a major complication incidence of 24.2%. The highest incidences of complications occurred in patients with the diagnosis of infection and tumor, where incidence exceeded 70%; this difference did not achieve statistical significance. The overall median LOS was 7 days; LOS was longer in patients with traumatic pathology (17 d) and patients with neoplastic pathology (14 d) (P<0.05).A higher incidence of complications than earlier studies was noted. A trend toward higher complication incidence in patients with infectious or neoplastic disease was observed. The severity of patient pathology, the broader definitions of complication used, and the elimination of recall bias by the use of a prospective study design accounts for the higher incidence of complications reported in this series. However, a large, prospective study using clear definitions is needed to elucidate the true incidence of early complications in thoracolumbar surgery.

    View details for DOI 10.1097/BSD.0b013e3181e12403

    View details for Web of Science ID 000288740200013

    View details for PubMedID 21445020

  • Lumbar Decompression Using a Traditional Midline Approach Versus a Tubular Retractor System Comparison of Patient-Based Clinical Outcomes SPINE Anderson, D. G., Patel, A., Maltenfort, M., Vaccaro, A. R., Ratliff, J., Hilibrand, A., Harrop, J. S., Sharan, A. D., Ponnappan, R. K., Rihn, J., Albert, T. J. 2011; 36 (5): E320-E325

    View details for DOI 10.1097/BRS.0b013e3181db1dfb

    View details for Web of Science ID 000287446300005

    View details for PubMedID 21178844

  • Incidence of Early Complications in Cervical Spine Surgery and Relation to Preoperative Diagnosis A Single-center Prospective Study JOURNAL OF SPINAL DISORDERS & TECHNIQUES Yadla, S., Malone, J., Campbell, P. G., Nasser, R., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2011; 24 (1): 50-54


    Prospective observational cohort study.To determine the incidence of early postoperative complications in patients undergoing cervical spine surgery and its correlation with preoperative diagnosis.The reported incidence of complications and adverse events in cervical spine surgery is highly variable. Inconsistent definitions and varying methodologies have made the interpretation of earlier reports difficult. No large study has analyzed the overall early morbidity of cervical spine surgery in a prospective fashion or attempted to correlate preoperative diagnosis and comorbidities with perioperative complications.Data on 121 consecutive patients, who underwent cervical spine surgery at the Thomas Jefferson University Hospital from May to December 2008, was prospectively collected. Complication definition and gradations of complication severity were validated by a survey of spine surgeons and spine surgery patients. An independent assessor prospectively audited complication incidence in the patient cohort. Data on diagnosis, comorbidities, BMI, complications, and length of stay were prospectively collected and assessed using stepwise multivariate analysis.The overall incidence of early complications was 47.1% with a 40.5% incidence of minor complications and an 18.2% incidence of major complications. Major complication incidence was greater in cases of infection (20.0%) and spinal oncologic procedures (30.0%), although this difference was not of statistical significance (P=0.07). Total number of complications recorded was greater in cases of infection and neoplasm (P=0.05).Complications in cervical spine procedures occurred most frequently in cases involving trauma and spinal oncologic procedures. This study illustrates that the incidence of early complications in cervical spine procedures is greater than appreciated earlier. This difference likely arises owing to the use of a broad definition of perioperative complications, elimination of recall bias through use of a prospective assessment, and overall case complexity. Accurate assessment of the incidence of early complications in cervical spine surgery is important for patient counseling and in design of prospective quality improvement programs.

    View details for DOI 10.1097/BSD.0b013e3181d0d0e8

    View details for Web of Science ID 000286622500012

    View details for PubMedID 20124909

  • High-resolution ultrasonography in the diagnosis and intraoperative management of peripheral nerve lesions Clinical article JOURNAL OF NEUROSURGERY Lee, F. C., Singh, H., Nazarian, L. N., Ratliff, J. K. 2011; 114 (1): 206-211


    The diagnosis of peripheral nerve lesions relies on clinical history, physical examination, electrodiagnostic studies, and radiography. Magnetic resonance neurography offers high-resolution visualization of structural peripheral nerve lesions. The availability of MR neurography may be limited, and the costs can be significant. By comparison, ultrasonography is a portable, dynamic, and economic technology. The authors explored the clinical applicability of high-resolution ultrasonography in the preoperative and intraoperative management of peripheral nerve lesions.The authors completed a retrospective analysis of 13 patients undergoing ultrasonographic evaluation and surgical treatment of nerve lesions at their institution (nerve entrapment [5], trauma [6], and tumor [2]). Ultrasonography was used for diagnostic (12 of 13 cases) and intraoperative management (6 of 13 cases). The authors examine the initial impact of ultrasonography on clinical management.Ultrasonography was an effective imaging modality that augmented electrophysiological and other neuroimaging studies. The modality provided immediate visualization of a sutured peroneal nerve after a basal cell excision, prompting urgent surgical exploration. Ultrasonography was used intraoperatively in 2 cases to identify postoperative neuromas after mastectomy, facilitating focused excision. Ultrasonography correctly diagnosed an inflamed lymph node in a patient in whom MR imaging studies had detected a schwannoma, and the modality correctly diagnosed a tendinopathy in another patient referred for ulnar neuropathy. Ultrasonography was used in 6 patients to guide the surgical approach and to aid in intraoperative localization; it was invaluable in localizing the proximal segment of a radial nerve sectioned by a humerus fracture. In all cases, ultrasonography demonstrated the correct lesion diagnosis and location (100%); in 7 (58%) of 12 cases, ultrasonography provided the correct diagnosis when other imaging and electrophysiological studies were inconclusive or inadequate.High-resolution ultrasonography may provide an economical and accurate imaging modality with utility in diagnosis and management of peripheral nerve lesions. Further research is required to assess the role of ultrasonography in evaluation of peripheral nerve pathology.

    View details for DOI 10.3171/2010.2.JNS091324

    View details for Web of Science ID 000285669500041

    View details for PubMedID 20225925

  • Neurologic Improvement After Thoracic, Thoracolumbar, and Lumbar Spinal Cord (Conus Medullaris) Injuries SPINE Harrop, J. S., Naroji, S., Maltenfort, M. G., Ratliff, J. K., Tjoumakaris, S. I., Frank, B., Anderson, D. G., Albert, T., Vaccaro, A. R. 2011; 36 (1): 21-25


    Retrospective.With approximately 10,000 new spinal cord injury (SCI) patients in the United States each year, predicting public health outcomes is an important public health concern. Combining all regions of the spine in SCI trials may be misleading if the lumbar and sacral regions (conus) have a neurologic improvement at different rates than the thoracic or thoracolumbar spinal cord.Over a 10-year period between January 1995 to 2005, 1746 consecutive spinal injured patients were seen, evaluated, and treated through a level 1 trauma referral center. A retrospective analysis was performed on 150 patients meeting the criteria of T4 to S5 injury, excluding gunshot wounds. One-year follow-up data were available on 95 of these patients.Contingency table analyses (chi-squared statistics) and multivariate logistic regression. Variables of interest included level of injury, initial American Spinal Injury Association (ASIA), age, race, and etiology.A total of 92.9% of lumbar (conus) patients neurologically improved one ASIA level or more compared with 22.4% of thoracic or thoracolumbar spinal cord-injured patients. Only 7.7% of ASIA A patients showed neurologic improvement, compared with 95.2% of ASIA D patients; ASIA B patients demonstrated a 66.7% improvement rate, whereas ASIA C had a 84.6% improvement rate. When the two effects were considered jointly in a multivariate analysis, ASIA A and thoracic/thoracolumbar patients had only a 4.1% rate of improvement, compared with 96% for lumbar (conus) and incomplete patients (ASIA B-D) and 66.7% to 72.2% for the rest of the patients. All of these relationships were significant to P < 0.001 (chi-square test). There was no link to age or gender, and race and etiology were secondary to region and severity of injury.Thoracic (T4-T9) SCIs have the least potential for neurologic improvement. Thoracolumbar (T10-T12) and lumbar (conus) spinal cord have a greater neurologic improvement rate, which might be related to a greater proportion of lower motor neurons. Thus, defining the exact region of injury and potential for neurologic improvement should be considered in future clinical trial design. Combining all anatomic regions of the spine in SCI trials may be misleading if different regions have neurologic improvement at different rates. Over a ten-year period, 95 complete thoracic/thoracolumbar SCI patients had only a 4.1% rate of neurologic improvement, compared with 96.0% for incomplete lumbar (conus) patients and 66.7% to 72.2% for all others.

    View details for DOI 10.1097/BRS.0b013e3181fd6b36

    View details for Web of Science ID 000285778700016

    View details for PubMedID 21192220

  • Impact of total disc arthroplasty on the surgical management of lumbar degenerative disc disease: Analysis of the Nationwide Inpatient Sample from 2000 to 2008. Surgical neurology international Awe, O. O., Maltenfort, M. G., Prasad, S., Harrop, J. S., Ratliff, J. K. 2011; 2: 139-?


    Spinal fusion is the most rapidly increasing type of lumbar spine surgery for various lumbar degenerative pathologies. The surgical treatment of lumbar spine degenerative disc disease may involve decompression, stabilization, or arthroplasty procedures. Lumbar disc athroplasty is a recent technological advance in the field of lumbar surgery. This study seeks to determine the clinical impact of anterior lumbar disc replacement on the surgical treatment of lumbar spine degenerative pathology. This is a retrospective assessment of the Nationwide Inpatient Sample (NIS).The NIS was searched for ICD-9 codes for lumbar and lumbosacral fusion (81.06), anterior lumbar interbody fusion (81.07), and posterolateral lumbar fusion (81.08), as well as for procedure codes for revision fusion surgery in the lumbar and lumbosacral spine (81.36, 81.37, and 81.38). To assess lumbar arthroplasty, procedure codes for the insertion or replacement of lumbar artificial discs (84.60, 84.65, and 84.68) were queried. Results were assayed from 2000 through 2008, the last year with available data. Analysis was done using the lme4 package in the R programming language for statistical computing.A total of nearly 300,000 lumbar spine fusion procedures were reported in the NIS database from 2000 to 2008; assuming a representative cross-section of the US health care market, this models approximately 1.5 million procedures performed over this time period. In 2005, the first year of its widespread use, there were 911 lumbar arthroplasty procedures performed, representing 3% of posterolateral fusions performed in this year. Since introduction, the number of lumbar spine arthroplasty procedures has consistently declined, to 653 total procedures recorded in the NIS in 2008. From 2005 to 2008, lumbar arthroplasties comprised approximately 2% of lumbar posterolateral fusions. Arthroplasty patients were younger than posterior lumbar fusion patients (42.8 ± 11.5 vs. 55.9 ± 15.1 years, P < 0.0000001). The distribution of arthroplasty procedures was even between academic and private urban facilities (48.5% and 48.9%, respectively). While rates of posterolateral lumbar spine fusion steadily grew during the period (OR 1.06, 95% CI: 1.05-1.06, P < 0.0000001), rates of revision surgery and anterior spinal fusion remained static.The impact of lumbar arthroplasty procedures has been minimal. Measured as a percentage of more common lumbar posterior arthrodesis procedures, lumbar arthroplasty comprises only approximately 2% of lumbar spine surgeries performed in the United States. Over the first 4 years following the Food and Drug Administration (FDA) approval, the frequency of lumbar disc arthroplasty has decreased while the number of all lumbar spinal fusions has increased.

    View details for DOI 10.4103/2152-7806.85980

    View details for PubMedID 22059134

  • Defining "Complications'' in Spine Surgery Neurosurgery and Orthopedic Spine Surgeons' Survey JOURNAL OF SPINAL DISORDERS & TECHNIQUES Lebude, B., Yadla, S., Albert, T., Anderson, D. G., Harrop, J. S., Hilibrand, A., Maltenfort, M., Sharan, A., Vaccaro, A. R., Ratliff, J. K. 2010; 23 (8): 493-500


    Survey of neurosurgical and orthopedic spine surgeons.To define the "complications of spinal surgery," we surveyed a large group of practicing spine surgeons to establish a preliminary definition of perioperative complications.Although the risk of complications following spinal procedures plays an important role in determining the appropriateness of surgical intervention, there is little consensus among spine surgeons regarding the definition of complications in spine surgery. The relevance of medical complications is also not clearly defined.We surveyed a cohort of practicing spine surgeons via email and a commercially maintained website. Surgeons were presented with various complication scenarios, and asked to assess the presence or absence of a complication, as well as complication severity, with responses limited to "major complication" and "minor complication/adverse event."The survey was sent to approximately 2000 practicing surgeons; complete responses were received from 229, giving a response rate of 11.4%. Orthopedic surgeons comprised the majority of respondents (73%); most surgeons reported being in practice for greater than 5 years (83%). Greater than 75% of surgeons agreed on complication presence or absence in 10 of 11 scenarios assessed (91%, P<0.05). Consensus (?70% agreement, P<0.05) as to type of complication was found in 7 of 11 scenarios presented (64%). Events deemed major complications involved either severe medical adverse events with permanent sequela or events requiring return to the operating room. Surgeons consistently considered medical adverse events, whether or not directly related to surgery, relevant to complication assessment.We present a practical binary definition of complications in spine surgery based upon a survey of over 200 practicing spine surgeons. Further work is required in critically assessing spine surgery complications.

    View details for DOI 10.1097/BSD.0b013e3181c11f89

    View details for Web of Science ID 000284942700009

    View details for PubMedID 20124913

  • Early complications in spine surgery and relation to preoperative diagnosis: a single-center prospective study Clinical article JOURNAL OF NEUROSURGERY-SPINE Yadla, S., Malone, J., Campbell, P. G., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2010; 13 (3): 360-366


    The reported incidence of complications in spine surgery varies widely. Variable study methodologies may open differing avenues for potential bias, and unclear definitions of perioperative complication make analysis of the literature challenging. Although numerous studies have examined the morbidity associated with specific procedures or diagnoses, no prospective analysis has evaluated the impact of preoperative diagnosis on overall early morbidity in spine surgery. To accurately assess perioperative morbidity in patients undergoing spine surgery, a prospective analysis of all patients who underwent spine surgery by the neurosurgical service at a large tertiary care center over a 6-month period was conducted. The correlation between preoperative diagnosis and the incidence of postoperative complications was assessed.Data were prospectively collected on 248 consecutive patients undergoing spine surgery performed by the neurosurgical service at the Thomas Jefferson University Hospital from May to December 2008. A standardized definition of minor and major complications was applied to all adverse events occurring within 30 days of surgery. Data on diagnosis, complications, and length of stay were retrospectively assessed using stepwise multivariate analysis. Patients were analyzed by preoperative diagnosis (neoplasm, infection, degenerative disease, trauma) and level of surgery (cervical or thoracolumbar).Total early complication incidence was 53.2%, with a minor complication incidence of 46.4% and a major complication incidence of 21.3%. Preoperative diagnosis correlated only with the occurrence of minor complications in the overall cohort (p = 0.02). In patients undergoing surgery of the thoracolumbar spine, preoperative diagnosis correlated with presence of a complication and the number of complications (p = 0.003). Within this group, patients with preoperative diagnoses of infection and neoplasm were more often affected by isolated and multiple complications (p = 0.05 and p = 0.02, respectively). Surgeries across the cervicothoracic and thoracolumbar junctions were associated with higher incidences of overall complication than cervical or lumbar surgery alone (p = 0.04 and p = 0.03, respectively). Median length of stay was 5 days for patients without a complication. Length of stay was significantly greater for patients with a minor complication (10 days, p < 0.0001) and even greater for patients with a major complication (14 days, p < 0.0001).The incidence of complications found in this prospective analysis is higher than that reported in previous studies. This association may be due to a greater accuracy of record-keeping, absence of recall bias via prospective data collection, high complexity of pathology and surgical approaches, or application of a more liberal definition of what constitutes a complication. Further large-scale prospective studies using clear definitions of complication are necessary to ascertain the true incidence of early postoperative complications in spine surgery.

    View details for DOI 10.3171/2010.3.SPINE09806

    View details for Web of Science ID 000281110800013

    View details for PubMedID 20809731

  • Early Complications Related to Approach in Cervical Spine Surgery: Single-Center Prospective Study WORLD NEUROSURGERY Campbell, P. G., Yadla, S., Malone, J., Zussman, B., Maltenfort, M. G., Sharan, A. D., Harrop, J. S., Ratliff, J. K. 2010; 74 (2-3): 363-368


    Surgical intervention is performed on the cervical spine in a heterogeneous number of pathologic conditions in a diverse patient population. Several authors have examined complication prevalence in cervical spine surgery using retrospective analysis. However, few prospective studies have directly examined perioperative complications. Most prospective studies in the spine literature have assessed only specific spinal implants in carefully selected surgical patients, and complication incidence in broader patient populations is limited.To prospectively collect data on all patients who underwent cervical spine surgery at a large tertiary care center and to evaluate the effect of the approach and the incidence of early complications.Data were collected prospectively on 119 patients admitted to the neurosurgical service at Thomas Jefferson University hospital from May to December 2008. Data collected consisted of preoperative diagnosis, medical comorbidities, body mass index, surgical approach, length of stay, and complications, and were analyzed using multivariate regression analysis. Complications occurring within 30 days after each operative procedure were included. Medical adverse events, regardless of their relationship to the operative intervention, were also included as complications. A previously validated binary definition of major and minor complications was used to stratify the data.Overall, 53 of 119 patients (44.5%) experienced at least one complication. Eleven of 41 patients (26.8%) undergoing only an anterior cervical procedure had a perioperative complication, compared with 26 of 53 patients (49.0%) undergoing only a posterior cervical procedure (P = .01). In patients undergoing a combined anterior and posterior surgical procedure, 16 of 25 (66%) experienced a complication, a significant difference in comparison with solitary anterior procedures (P = .004). Anterior procedures were associated with postoperative dysphagia and vocal cord paresis, whereas wound infection and C5 palsy was more frequently recorded in the group undergoing surgery via an isolated posterior approach.The incidence of complications or adverse events is not definitely known for most spinal procedures because of the complexity of defining complications and obtaining accurate data. Therefore, to obtain a more accurate assessment of spinal procedures, a prospective algorithm was designed to collect and record complications during the acute perioperative period. Using this technique, a significantly higher complication rate was documented than had been previously reported for cervical spine operative interventions. In addition, use of a broad definition of perioperative complications likely increased the recorded incidence of perioperative adverse events and complications. Complications were more common in patients undergoing posterior and anteroposterior procedures.

    View details for DOI 10.1016/j.wneu.2010.05.034

    View details for Web of Science ID 000292781100041

    View details for PubMedID 21492571

  • Complications in spine surgery A review JOURNAL OF NEUROSURGERY-SPINE Nasser, R., Yadla, S., Maltenfort, M. G., Harrop, J. S., Anderson, D. G., Vaccaro, A. R., Sharan, A. D., Ratliff, J. K. 2010; 13 (2): 144-157


    The overall incidence of complications or adverse events in spinal surgery is unknown. Both prospective and retrospective analyses have been performed, but the results have not been critically assessed. Procedures for different regions of the spine (cervical and thoracolumbar) and the incidence of complications for each have been reported but not compared. Authors of previous reports have concentrated on complications in terms of their incidence relevant to healthcare providers: medical versus surgical etiology and the relevance of perioperative complications to perioperative events. Few authors have assessed complication incidence from the patient's perspective. In this report the authors summarize the spine surgery complications literature and address the effect of study design on reported complication incidence.A systematic evidence-based review was completed to identify within the published literature complication rates in spinal surgery. The MEDLINE database was queried using the key words "spine surgery" and "complications." This initial search revealed more than 700 articles, which were further limited through an exclusion process. Each abstract was reviewed and papers were obtained. The authors gathered 105 relevant articles detailing 80 thoracolumbar and 25 cervical studies. Among the 105 articles were 84 retrospective studies and 21 prospective studies. The authors evaluated the study designs and compared cervical, thoracolumbar, prospective, and retrospective studies as well as the durations of follow-up for each study.In the 105 articles reviewed, there were 79,471 patients with 13,067 reported complications for an overall complication incidence of 16.4% per patient. Complications were more common in thoracolumbar (17.8%) than cervical procedures (8.9%; p < 0.0001, OR 2.23). Prospective studies yielded a higher incidence of complications (19.9%) than retrospective studies (16.1%; p < 0.0001, OR 1.3). The complication incidence for prospective thoracolumbar studies (20.4%) was greater than that for retrospective series (17.5%; p < 0.0001). This difference between prospective and retrospective reviews was not found in the cervical studies. The year of study publication did not correlate with the complication incidence, although the duration of follow-up did correlate with the complication incidence (p = 0.001).Retrospective reviews significantly underestimate the overall incidence of complications in spine surgery. This analysis is the first to critically assess differing complication incidences reported in prospective and retrospective cervical and thoracolumbar spine surgery studies.

    View details for DOI 10.3171/2010.3.SPINE09369

    View details for Web of Science ID 000280405000003

    View details for PubMedID 20672949

  • Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures SPINE JOURNAL Yadla, S., Malone, J., Campbell, P. G., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Vaccaro, A. R., Ratliff, J. K. 2010; 10 (7): 581-587


    The correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship.The purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort.Prospective observational cohort study at a tertiary care facility.Cohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008).Incidence of perioperative complications (those occurring within 30 days of surgery).A prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression.Mean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58).This prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.

    View details for DOI 10.1016/j.spinee.2010.03.001

    View details for Web of Science ID 000279858800002

    View details for PubMedID 20409758

  • Impact of a Standardized Protocol and Antibiotic-Impregnated Catheters on Ventriculostomy Infection Rates in Cerebrovascular Patients NEUROSURGERY Harrop, J. S., Sharan, A. D., Ratliff, J., Prasad, S., Jabbour, P., Evans, J. J., Veznedaroglu, E., Andrews, D. W., Maltenfort, M., Liebman, K., Flomenberg, P., Sell, B., Baranoski, A. S., Fonshell, C., Reiter, D., Rosenwasser, R. H. 2010; 67 (1): 187-191


    Ventriculostomy infections create significant morbidity. To reduce infection rates, a standardized evidence-based catheter insertion protocol was implemented. A prospective observational study analyzed the effects of this protocol alone and with antibiotic-impregnated ventriculostomy catheters.To compare infection rates after implementing a standardized protocol for ventriculostomy catheter insertion with and without the use of antibiotic-impregnated catheters.Between 2003 and 2008, 1961 ventriculostomies and infections were documented. A ventriculostomy infection was defined as 2 positive CSF cultures from ventriculostomy catheters with a concurrent increase in cerebrospinal fluid white blood cell count. A baseline (preprotocol) infection rate was established (period 1). Infection rates were monitored after adoption of the standardized protocol (period 2), institution of antibiotic-impregnated catheter A (period 3), discontinuation of antibiotic-impregnated catheter A (period 4), and institution of antibiotic-impregnated catheter B (period 5).The baseline infection rate (period 1) was 6.7% (22/327 devices). Standardized protocol (period 2) implementation did not change the infection rate (8.2%; 23/281 devices). Introduction of catheter A (period 3) reduced infections to 1.0% (2/195 devices, P=.0005). Because of technical difficulties, this catheter was discontinued (period 4), resulting in an increase in infection rate (7.6%; 12/157 devices). Catheter B (period 5) significantly decreased infections to 0.9% (9 of 1001 devices, P=.0001). The Staphylococcus infection rate for periods 1, 2, and 4 was 6.1% (47/765) compared with 0.2% (1/577) during use of antibiotic-impregnated catheters (periods 3 and 5).The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

    View details for DOI 10.1227/01.NEU.0000370247.11479.B6

    View details for Web of Science ID 000278875400048

    View details for PubMedID 20559105

  • Dorsal Epidural Intervertebral Disk Herniation With Atypical Radiographic Findings: Case Report and Literature Review JOURNAL OF SPINAL CORD MEDICINE Teufack, S. G., Singh, H., Harrop, J., Ratliff, J. 2010; 33 (3): 268-271


    Intervertebral disk herniation is relatively common. Migration usually occurs in the ventral epidural space; rarely, disks migrate to the dorsal epidural space due to the natural anatomical barriers of the thecal sac.Case report.A 49-year-old man presented with 1 week of severe back pain with bilateral radiculopathy to the lateral aspect of his lower extremities and weakness of the ankle dorsiflexors and toe extensors. Lumbar spine magnetic resonance imaging with gadolinium revealed a peripheral enhancing dorsal epidural lesion with severe compression of the thecal sac. Initial differential diagnosis included spontaneous hematoma, synovial cyst, and epidural abscess. Posterior lumbar decompression was performed; intraoperatively, the lesion was identified as a large herniated disk fragment.Dorsal migration of a herniated intervertebral disk is rare and may be difficult to definitively diagnose preoperatively. Dorsal disk migration may present in a variety of clinical scenarios and, as in this case, may mimic other epidural lesions on magnetic resonance imaging.

    View details for Web of Science ID 000281007700011

    View details for PubMedID 20737802

  • Pilomatrix Carcinoma of the Thoracic Spine: Case Report and Review of the Literature JOURNAL OF SPINAL CORD MEDICINE Yadia, S., Randazzo, C. G., Malik, S., Gressen, E., Chasky, M., Kenyon, L. C., Ratliff, J. K. 2010; 33 (3): 272-277


    Pilomatrixoma is a common head and neck neoplasm in children. Its malignant counterpart, pilomatrix carcinoma, is rare and found more often in men.Case report of a 21-year-old man with pilomatrixoma of the thoracic spine that underwent malignant degeneration to pilomatrix carcinoma.The appearance of a painless mobile axillary mass was followed by severe back pain 1 year later. Imaging revealed a compression fracture at the T5 level. The patient underwent resection of the axillary mass and spinal reconstruction of the fracture; the pathology was consistent with synchronous benign pilomatrixomas. Three months later he presented with a recurrence of the spinal lesion and underwent further surgical resection; the pathology was consistent with pilomatrix carcinoma. He received adjuvant radiotherapy and at his 1-year follow-up examination had no sign of recurrence.Pilomatrix carcinoma involving the spine is a rare occurrence. It has a high incidence of local recurrence, and wide excision may be necessary to reduce this risk. Radiotherapy may be a helpful adjuvant therapy. Clinicians should be aware of this entity because of its potential for distant metastasis.

    View details for Web of Science ID 000281007700012

    View details for PubMedID 20737803

  • Correlation of C2 Fractures and Vertebral Artery Injury SPINE Ding, T., Maltenfort, M., Yang, H., Smith, H., Ratliff, J., Vaccaro, A., Anderson, D. G., Harrop, J. 2010; 35 (12): E520-E524


    Retrospective review of prospectively collected data.Vertebral artery injuries (VAI) occur commonly after cervical spine trauma. No study has yet examined the association between VAI and specific variants of C2 fractures.To evaluate the incidence of VAI (as defined by magnetic resonance imaging/angiography [MRI/A]) in subtypes of C2 fractures. To define the association between the incidence, morphology, and severity of C2 fractures, based on fracture angulation and comminution, and the occurrence of VAI.Patients admitted to the hospital with C2 fractures between October 2006 and December 2008 to a tertiary care referral center were identified through a prospectively maintained database. Computed tomography (CT) and MRI/A studies were individually reviewed to evaluate the specific C2 fracture type and the occurrence of VAI. Fracture displacement and angulation were measured. Incidence of VAI was compared between different types and subtypes of C2 fractures. The effects of displacement and angulation of the fracture, morphology of foramen transversarium fracture, patient age, and patient gender on VAI were also analyzed.One hundred one patients were identified with C2 fractures that met inclusion criteria, and 18 (17.8%) had VAI by MRI/A. There was no correlation between fracture types and VAI. However, in subtype analysis, there was a correlation of VAI with traumatic spondylolisthesis of axis (TSA) and greater degree of angulation (P = 0.0023), communition fracture (P = 0.0341), and presence of bone fragment(s) within the foramen transversarium (P = 0.0075). Multivariate logistic regression indicated that age, gender and the presence of fragments within foramen transversarium were associated with greater risk of VAI.Vertebral artery injuries are more likely to occur in C2 fractures with comminuted fractures involving the foramen transversarium, with fractures manifesting bony fragment(s) within the foramen transversarium, or with fractures having greater angulation. These risk factors should be considered when a patient presents with isolated axis fracture.

    View details for DOI 10.1097/BRS.0b013e3181cd98b6

    View details for Web of Science ID 000278074400006

    View details for PubMedID 20445475

  • Early Complications Related to Approach in Thoracic and Lumbar Spine Surgery: A Single Center Prospective Study WORLD NEUROSURGERY Campbell, P. G., Malone, J., Yadla, S., Maltenfort, M. G., Harrop, J. S., Sharan, A. D., Ratliff, J. K. 2010; 73 (4): 395-401


    Thoracic and lumbar spine surgical procedures are performed for a variety of pathologies. The literature consists of multiple retrospective reviews examining complication prevalence with the surgical treatment of these disorders. However, there is limited direct examination of perioperative complications through a prospective approach. Of the prospective assessments, the majority focuses on specific surgical procedures or provides a limited assessment of certain spinal implants. Prospective assessments of complication incidence in broad patient populations are limited. This article analyzes a prospectively collected database of patients who underwent a thoracic and/or lumbar spine surgery at a large tertiary care center and the effect of surgical approach (anterior or posterior) on the incidence of early complications.Data collection was performed prospectively on 128 patients on the neurosurgical spine service at Thomas Jefferson University hospital from May to December 2008. Data on preoperative diagnosis, medical comorbidities, body mass index, surgical approach and procedure, length of stay, and complication occurrence was recorded and analyzed. Acute complications or adverse events occurring within the initial 30 days after each operative procedure were included. All medical adverse events were included as complications. A previously circumstantiated binary definition of major and minor complications was used to stratify the data.Overall, 76 of 128 patients (59.4%) in this cohort experienced at least one complication. Anterior thoracic and lumbar procedures had an 83.3% (5/6) incidence of complications. Of those patients having solely a posterior thoracic and lumbar procedures, 37 of 75 (49.3%) experienced at least one complication. Combined anterior and posterior surgical procedure had a complication incidence of 34 of 47 (72.3%). The mean number of complications reached significance for the minor and overall complications groups (P = .0076 and .0172, respectively, Poisson regression). Comparing the incidence of complications reveals the overall complications in the posterior alone group compared with the anterior/posterior combined group was significantly lower (P = .0134). Those undergoing instrumented fusions were statistically more likely to encounter complications (P < .001).There is a considerably higher complication incidence than previously reported for thoracic, thoracolumbar, and lumbar spine operations. A prospective approach and a broad definition of perioperative complications increased the recorded incidence of perioperative adverse events and complications. The case complexity of a tertiary referral center may also have escalated the increased incidence. Complications were more common in patients undergoing anterior and anterior/posterior procedures.

    View details for DOI 10.1016/j.wneu.2010.01.024

    View details for Web of Science ID 000292775600059

    View details for PubMedID 20849799

  • Cervical Myelopathy A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy SPINE Harrop, J. S., Naroji, S., Maltenfort, M., Anderson, D. G., Albert, T., Ratliff, J. K., Ponnappan, R. K., Rihn, J. A., Smith, H. E., Hilibrand, A., Sharan, A. D., Vaccaro, A. 2010; 35 (6): 620-624
  • Adult scoliosis surgery outcomes: a systematic review NEUROSURGICAL FOCUS Yadla, S., Maltenfort, M. G., Ratliff, J. K., Harrop, J. S. 2010; 28 (3)


    Appreciation of the optimal management of skeletally mature patients with spinal deformities requires understanding of the natural history of the disease relative to expected outcomes of surgical intervention. Appropriate outcome measures are necessary to define the surgical treatment. Unfortunately, the literature lacks prospective randomized data. The majority of published series report outcomes of a particular surgical approach, procedure, or surgeon. The purpose of the current study was to systematically review the present spine deformity literature and assess the available data on clinical and radiographic outcome measurements.A systematic review of MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: "adult scoliosis surgery," "adult spine deformity surgery," "outcomes," and "complications." Exclusion criteria included follow-up shorter than 2 years and mean patient age younger than 18 years. Data on major curve (coronal scoliosis or lumbar lordosis Cobb angle as reported), major curve correction, Oswestry Disability Index (ODI) scores, Scoliosis Research Society (SRS) instrument scores, complications, and pseudarthroses were recorded.Forty-nine articles were obtained and included in this review; 3299 patient data points were analyzed. The mean age was 47.7 years, and the mean follow-up period was 3.6 years. The average major curve correction was 26.6 degrees (for 2188 patients); for 2129 patients, it was possible to calculate average curve reduction as a percentage (40.7%). The mean total ODI was 41.2 (for 1289 patients), and the mean postoperative reduction in ODI was 15.7 (for 911 patients). The mean SRS-30 equivalent score was 97.1 (for 1700 patients) with a mean postoperative decrease of 23.1 (for 999 patients). There were 897 reported complications for 2175 patients (41.2%) and 319 pseudarthroses for 2469 patients (12.9%).Surgery for adult scoliosis is associated with improvement in radiographic and clinical outcomes at a minimum 2-year follow-up. Perioperative morbidity includes an approximately 13% risk of pseudarthrosis and a greater than 40% incidence of perioperative adverse events. Incidence of perioperative complications is substantial and must be considered when deciding optimal disease management. Although the quality of published studies in this area has improved, particularly in the last few years, the current review highlights the lack of routine use of standardized outcomes measures and assessment in the adult scoliosis literature.

    View details for DOI 10.3171/2009.12.FOCUS09254

    View details for Web of Science ID 000275048800004

    View details for PubMedID 20192664

  • Potential financial impact of restriction in "never event" and periprocedural hospital-acquired condition reimbursement at a tertiary neurosurgical center: a single-institution prospective study Clinical article JOURNAL OF NEUROSURGERY Teufack, S. G., Campbell, P., Jabbour, P., Maltenfort, M., Evans, J., Ratliff, J. K. 2010; 112 (2): 249-256


    The Centers for Medicare and Medicaid Services (CMS) have moved to limit hospital augmentation of diagnosis-related group billing for "never events" (adverse events that are serious, largely preventable, and of concern to the public and health care providers for the purpose of public accountability) and certain hospital-acquired conditions (HACs). Similar restrictions may be applied to physician billing. The financial impact of these restrictions may fall on academic medical centers, which commonly have populations of complex patients with a higher risk of HACs. The authors sought to quantify the potential financial impact of restrictions in never events and periprocedural HAC billing on a tertiary neurosurgery facility.Operative cases treated between January 2008 and June 2008 were reviewed after searching a prospectively maintained database of perioperative complications. The authors assessed cases in which there was a 6-month lag time to allow for completion of hospital and physician billing. They speculated that other payers would soon adopt the present CMS restrictions and that procedure-related HACs would be expanded to cover common neurosurgery procedures. To evaluate the impact on physician billing and to directly contrast physician and hospital billing impact, the authors focused on periprocedural HACs, as opposed to entire admission HACs. Billing records were compiled and a comparison was made between individual event data and simultaneous cumulative net revenue and net receipts. The authors assessed the impact of the present regulations, expansion of CMS restrictions to other payers, and expansion to rehospitalization and entire hospitalization case billing due to HACs and never events.A total of 1289 procedures were completed during the examined period. Twenty-five procedures (2%) involved patients in whom HACs developed; all were wound infections. Twenty-nine secondary procedures were required for this cohort. Length of stay was significantly higher in patients with HACs than in those without (11.6 +/- 11.5 vs 5.9 +/- 7.0 days, respectively). Fifteen patients required readmission due to HACs. Following present never event and HAC restrictions, hospital and physician billing was minimally affected (never event billing as percent total receipts was 0.007% for hospitals and 0% for physicians). Nonpayment for rehospitalization and reoperation for HACs by CMS and private payers yielded greater financial impact (CMS only, percentage of total receipts: 0.14% hospital, 0.2% physician; all payers: 1.56% hospital, 3.0% physician). Eliminating reimbursement for index procedures yielded profound reductions (CMS only as percentage of total receipts: 0.62% hospital, 0.8% physician; all payers: 5.73% hospital, 8.9% physician).The authors found potentially significant reductions in physician and facility billing. The expansion of never event and HACs reimbursement nonpayment may have a substantial financial impact on tertiary care facilities. The elimination of never events and reduction in HACs in current medical practices are worthy goals. However, overzealous application of HACs restrictions may remove from tertiary centers the incentive to treat high-risk patients.

    View details for DOI 10.3171/2009.7.JNS09753

    View details for Web of Science ID 000274107000008

    View details for PubMedID 19681681

  • Cervical Myelopathy: A Clinical and Radiographic Evaluation and Correlation to Cervical Spondylotic Myelopathy. Spine Harrop, J. S., Naroji, S., Maltenfort, M., Anderson, D. G., Albert, T., Ratliff, J. K., Ponnappan, R. K., Rihn, J. A., Smith, H. E., Hilibrand, A., Sharan, A. D., Vaccaro, A. 2010


    STUDY DESIGN.: Retrospective analysis of a cohort of patients treated between April 2006 and January 2008, and diagnosed with cervical degenerative disease. OBJECTIVE.: To determine the correlation of the clinical findings associated with cervical myelopathy to the presence of spinal cord compression or cord signal abnormalities on magnetic resonance imaging (MRI). BACKGROUND.: There are numerous reports describing the radiographic features of cervical spondylosis, however, no publication specifically describes the association between the physical signs of cervical myelopathy and the presenting imaging findings. METHODS.: Myelopathy was defined as the presence of greater than one long-tract sign localized to the cervical spinal cord (Hoffman or Babinski signs, clonus, hyper-reflexia, crossed abductor sign, and/or gait dysfunction) on physical examination in the absence of other neurologic condition(s). The presence of these signs, MRI imaging features of spinal cord compression and hyperintense T2 intraparenchymal cord signal abnormality, and patient demographics were recorded. RESULTS.: One hundred three patients met inclusion criteria (age >18, symptomatic cervical degenerative disease and complete neurologic assessment). Of these, 54 had clinical findings of cervical myelopathy. Radiographic features of cord compression were present in 62% of patients, and 84% had myelopathy on examination. No patients without cord compression presented with myelopathy (P < 0.0001). Thirty-five percent of the patients presented with hyperintense signal on T2 MRI within the spinal cord parenchyma. This finding correlated with the presence of myelopathy (P < 0.0001). Multivariate analysis on the subset with cord compression indicates that the likelihood of myelopathy increased with the presence of cord signal hyperintensity (odds ratio [OR], 11.4), sensory loss (OR, 16.9), and age (OR, 1.10 per year). CONCLUSION.: The diagnosis of cervical myelopathy is based on presenting symptoms and physical examination. This analysis illustrates that radiographic cervical spinal cord compression and hyperintense T2 intraparenchymal signal abnormalities correlate with the presence of myelopathic findings on physical examination.

    View details for PubMedID 20150835

  • Iliac Bolt Fixation An Anatomic Approach JOURNAL OF SPINAL DISORDERS & TECHNIQUES Harrop, J. S., Jeyamohan, S. B., Sharan, A., Ratliff, J., Vaccaro, A. R. 2009; 22 (8): 541-544


    An illustrative technique display and discussions.Review of traditional and new "anatomic" techniques for placement of iliac-spinal fixation.Placement of iliac fixation traditionally has been performed using offset connectors, devascularizing the iliac muscles, in addition to the posterior iliac spine. The technique reviewed provides for the screw heads to be placed in a more anatomic position, allowing rods to be laid parallel without the detachment of the erector spinous muscles.Utilization of anatomic models and discussion of present surgical technique for iliac bolt fixation (traditional) compared and contrasted to newer technique using the anatomic landmarks and structures of the iliac crest.The anatomic models illustrate and support the utilization of an anatomic technique for fixation due to the lessening of muscle trauma, alignment of the rod systems, and preservation of the cortical surfaces.The anatomic placement of iliac bolts provides for improved alignment of constructs while addressing spinal deformities. It may also increase screw pullout and construct strength.

    View details for DOI 10.1097/BSD.0b013e31818da3e2

    View details for Web of Science ID 000279665500001

    View details for PubMedID 19956026

  • Complications in spinal surgery: comparative survey of spine surgeons and patients who underwent spinal surgery Clinical article JOURNAL OF NEUROSURGERY-SPINE Ratliff, J. K., Lebude, B., Albert, T., Anene-Maidoh, T., Anderson, G., Dagostino, P., Maltenfort, M., Hilibrand, A., Sharan, A., Vaccaro, A. R. 2009; 10 (6): 578-584


    Definitions of complications in spinal surgery are not clear. Therefore, the authors assessed a group of practicing spine surgeons and, through the surgeons' responses to an online and emailed survey, developed a simple definition of operative complications due to spinal surgery. To validate this assessment, the authors revised their survey to make it appropriate for a lay audience and repeated the assessment with a cohort of patients who underwent spine surgery.The authors surveyed a cohort of practicing spine surgeons via email and a web-based survey. Surgeons were presented with various complication scenarios and were asked to grade the presence or absence of a complication as well as complication severity, with responses limited to "major complication" and "minor complication/adverse event." The authors administered a similar assessment, modified for lay persons, to patients in a spinal surgery clinic.Complete responses were obtained from 229 surgeons; orthopedic surgeons comprised the majority of respondents (73%). The authors obtained completed surveys from 197 patients. Overall, there was consistent agreement between physicians and patients regarding the presence or absence of a complication in the majority of scenarios (8 [73%] of 11 scenarios with agreement that a complication was present). The overall kappa value, evaluating major versus minor complication, and presence or absence of a complication over the entire cohort, was fair (kappa = 0.21). The authors found greater variation between the cohorts when evaluating complication severity. Patients were consistently more critical than physicians in the majority of scenarios in which a difference was evident. In 4 scenarios, patients were more likely than surgeons to deem the scenario a complication and to grade the complication as major versus minor (p < 0.01). In 3 additional scenarios, patients were more likely than physicians to grade a major complication as opposed to minor complication (p < 0.01). In only 1 scenario were patients less likely than physicians to report a complication (p < 0.001).Comparing responses of spine surgeons and patients who underwent spinal surgery in assessing a group of common postoperative events, the authors found significant agreement on perception of presence of a complication in the majority of scenarios reviewed. However, patients were consistently more critical than surgeons when differences in reporting were found. The authors' data underscore the importance of reconciling differing opinions regarding complications through open discussions between physicians and patients to ensure accurate patient expectations of planned medical or surgical interventions.

    View details for DOI 10.3171/2009.2.SPINE0935

    View details for Web of Science ID 000266461000010

    View details for PubMedID 19558291

  • Clinical survey: patterns of utilization of lumbar epidural steroid injections by a cohort of spinal surgeons. PM & R : the journal of injury, function, and rehabilitation Lebude, B., Wang, D., Harrop, J. S., Maltenfort, M., Anderson, D. G., Vaccaro, A. R., Ratliff, J. K. 2009; 1 (4): 329-334


    There are few data on responses to conservative therapy in the management of lumbar degenerative diseases. To understand the use of epidural steroid injections (ESIs) by spine surgeons in the treatment of 2 distinct lumbar spinal conditions-herniated nucleus pulposus (HNP) and degenerative disk disease (DDD)-a survey of orthopedic and neurosurgical spine surgeons was conducted.Participants were surveyed via posting of a survey on a commercially maintained Web site. Respondents were queried on individual preferences regarding epidural steroid injections for HNP and DDD.N/A.The survey was completed by 61 surgeons; not all surgeons completed the entire survey. There was equal representation between orthopedic and neurosurgical spine surgeons; most surgeons reported being in practice for greater than 10 years (41%) and most surgeons reported completing between either 50 and 100 or 100 and 200 spine surgeries each year (26% and 31%).Results were tabulated and assessed for variance. Both individual responses to the different ESI treatment protocols offered and difference in use of lumbar epidural steroids between diagnoses were analyzed.In treatment of lumbar HNP, the majority of respondents considered ESIs after 6 weeks of noninterventional care (69%). In lumbar DDD, there was no consensus as to overall use, timing, number of ESIs constituting a treatment regimen, number of treatment cycles recommended, and length of treatment before considering other intervention. In comparing treatment of lumbar HNP or DDD, there was no agreement with regard to timing of ESIs, with regard to duration of treatment, nor with regard to number of injections comprising a treatment regimen (kappa = -0.01, 0.03, and -0.02, respectively).No consensus was found as to timing, frequency, and duration of ESI treatment in lumbar HNP and DDD patients in a survey of practicing spine surgeons. These results illustrate one example of lack of consensus in conservative treatment protocols.

    View details for DOI 10.1016/j.pmrj.2008.11.013

    View details for PubMedID 19627915

  • Clinical Survey: Patterns of Utilization of Lumbar Epidural Steroid Injections by a Cohort of Spinal Surgeons PM&R Lebude, B., Wang, D., Harrop, J. S., Maltenfort, M., Anderson, D. G., Vaccaro, A. R., Ratliff, J. K. 2009; 1 (4): 329-334
  • Pseudarthrosis Following Lumbar Interbody Fusion Using Bone Morphogenetic Protein-2: Intraoperative and Histopathologic Findings ORTHOPEDICS Whang, P. G., O'Hara, B. J., Ratliff, J., Sharan, A., Brown, Z., Vaccaro, A. R. 2008; 31 (10): 1031-1034

    View details for Web of Science ID 000259984000018

    View details for PubMedID 19226004

  • Traumatic spondyloptosis of the thoracolumbar spine JOURNAL OF NEUROSURGERY-SPINE Yadla, S., Lebude, B., Tender, G. C., Sharan, A. D., Harrop, J. S., Hilibrand, A. S., Vaccaro, A. R., Ratliff, J. K. 2008; 9 (2): 145-151


    Traumatic Grade V thoracolumbar spondylolisthesis, or traumatic spondyloptosis (severe translation injuries), are uncommon spinal injuries. To the best of the authors' knowledge, this article represents the first reported case series of these unique spinal lesions.The authors undertook a retrospective review of a tertiary care regional spinal cord injury patient population treated over a 10-year period (1997-2007). They analyzed data regarding age, sex, mechanism of injury, neurological status, and treatment.Five patients were identified (3 men and 2 women) with ages ranging from 17 to 44 years. All patients had sustained high-energy closed spinal injuries: 3 motor vehicle accidents, 1 injured in a building collapse, and 1 hurt by a fallen steel beam. Four patients, all with sagittal-plane spondyloptosis, had a complete neurological deficit (American Spinal Injury Association [ASIA] Grade A), and 1, with coronal-plane spondyloptosis, presented with an incomplete neurological deficit (ASIA Grade C). Four patients had sustained concurrent multisystem trauma. All patients underwent surgery: an isolated posterior fusion in 2 and combined posterior-anterior fusion in 3. Only the patient with an incomplete neurological deficit (coronal-plane spondyloptosis) recovered neurological function postoperatively.Traumatic thoracolumbar junction spondyloptosis is rare. Surgical reconstruction and stabilization allow for early mobilization and rehabilitation. In the present series, a patient with coronal-plane spondyloptosis presented with preserved neurological function. This may be due to the result of differences in resultant neurological compression due to displacement mechanics compared with sagittally displaced injuries.

    View details for DOI 10.3171/SPI/2008/9/8/145

    View details for Web of Science ID 000257958200005

    View details for PubMedID 18764746

  • Spine-related expenditures and self-reported health status JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Ratliff, J., Hilibrand, A., Vaccaro, A. R. 2008; 299 (22): 2627-2627

    View details for Web of Science ID 000256586200014

    View details for PubMedID 18544720

  • Spinal injuries after falls from hunting tree stands SPINE JOURNAL Fayssoux, R. S., TALLY, W., SANFILIPPO, J. A., Stock, G., Ratliff, J. K., Anderson, G., Hilibrand, A. S., Albert, T. J., Vaccaro, A. R. 2008; 8 (3): 522-528


    Spinal injuries are common sequelae of falls from hunting tree stands. Significant neurological injury is not uncommon and can result in significant morbidity as well as enormous expenditure of health care dollars. Recent literature on the subject is limited.The purpose of this study was to identify precipitating causes, characterize the spectrum of spinal injury, and determine potential interventional safety and prevention recommendations.A retrospective study.Medical record review of 22 patients admitted either directly or via referral to a level I spinal cord injury referral center over a 10-year period (1995-2005) after a fall from a hunting tree stand.All patients were men with a mean age of 46 years (range, 27-80 years). Initial acute care hospitalization averaged 10 days (range, 2-28 days). The average height of fall was 18 feet (range, 10-30 feet). Four of 19 falls (21%) occurred during the morning hours, 2 of 19 falls occurred during the afternoon, and 13 of 19 falls (68%) occurred during the evening hours. Time lapse from injury to presentation to an emergency department ranged from 30 minutes to 14 hours. Alcohol use was a factor in 2 of 20 falls (10%). Hypothermia complicated 3 of 21 cases (14%). Associated injuries were present in 12 of 21 patients (57%) and included fractures to the axial and appendicular skeleton, pneumothoraces, a retroperitoneal bleed, and a brachial plexopathy. Eight of 22 patients (37%) sustained injury to the cervical spine. Five of these 8 patients (63%) had neurological deficits (3 complete and 2 incomplete spinal cord injuries). Thirteen of 22 (59%) patients sustained injury to the thoracic or lumbar spine. Ten of these 13 (77%) had neurologic deficits (3 complete and 7 incomplete). Nine of 22 (41%) patients were treated nonoperatively; the remaining 13 (59%) underwent operative intervention.Falls from hunting tree stands remain a significant cause of spinal injury and subsequent disability. The best intervention for these injuries is prevention. There is a continued need for hunter safety education to reduce the incidence of these injuries with emphasis on safety harness usage, proper installation and annual inspection of tree stands, hunting in groups with periodic contact, the use of communication devices, and abstinence from alcohol consumption while hunting.

    View details for DOI 10.1016/j.spinee.2006.11.005

    View details for Web of Science ID 000256181300014

    View details for PubMedID 18023620

  • Whiplash: diagnosis, treatment, and associated injuries. Current reviews in musculoskeletal medicine Yadla, S., Ratliff, J. K., Harrop, J. S. 2008; 1 (1): 65-68


    Focused review of the current literature.To identify and synthesize the most current data pertaining to the diagnosis and treatment of whiplash and whiplash-associated disorders (WAD), and to report on whiplash-related injuries.A search of OVID Medline (1996-January 2007) and the Cochrane database of systematic reviews was performed using the keywords whiplash and WAD. Articles under subheadings for pathology, diagnosis, treatment, and epidemiology were chosen for review after identification by the authors.A total of 485 articles in the English language literature were identified. Thirty-six articles pertained to the diagnosis, treatment, epidemiology of whiplash, and WAD, and were eligible for focused review. From these, 21 primary and 15 secondary sources were identified for full review. In addition, five articles were found that focused on whiplash associated cervical injuries. These five articles were also primary sources.Whiplash is a common injury associated most often with motor vehicle accidents. It may present with a variety of clinical manifestations, collectively termed WAD. Whiplash is an important cause of chronic disability. Many controversies exist regarding the diagnosis and treatment of whiplash injuries. The multifactorial etiology, believed to underly whiplash injuries, make management highly variable between patients. Radiographic evidence of injury often cannot be identified in the acute phase. Recent studies suggest early mobilization may lead to improved outcomes. Ligamentous and bony injuries may go undetected at initial presentation leading to delayed diagnosis and inappropriate therapies.

    View details for DOI 10.1007/s12178-007-9008-x

    View details for PubMedID 19468901

  • Acute cervical fracture or congenital spinal deformity? JOURNAL OF SPINAL CORD MEDICINE Harrop, J. S., Jeyamohan, S., Sharan, A., Ratliff, J., Flanders, A., Maltenfort, M., Falowski, S., Vaccaro, A. 2008; 31 (1): 83-87


    There are few reports of developmental or congenital cervical spinal deformities. Such cases may be mistaken for traumatically induced fractures, and additional treatment may ensue.A retrospective analysis was performed to identify patients with congenital cervical spine deformities. These patients were matched with a confirmed traumatic spinal fracture population with similar demographic features. Patients were analyzed for age, gender, imaging findings (plain roentgenograms including dynamic flexion and extension views, computed tomography scan, and MRI), neurologic status, and subjective complaints of pain.Thirty-six individuals were included in the final analysis, 7 with congenital abnormalities and 29 with radiographically confirmed traumatic injuries. Patients with congenital abnormalities had significantly less soft-tissue swelling compared with the population with traumatic fractures (P < 0.001). Furthermore, those with congenital defects presented with lesser degrees of vertebral subluxation (0.29 mm vs 7.24 mm) (P < 0.0001) and without neurologic deficits (P < 0.0001).Congenital abnormalities, though rare, can be mistaken for traumatic fractures of the spine. Physicians should note any evidence of soft-tissue swelling, neurologic deficits, degree of subluxation, and radiographic evidence of pedicle absence because these characteristics often provide insight into the specific etiology of the observed spinal deformity (congenital vs traumatic).

    View details for Web of Science ID 000256163400013

    View details for PubMedID 18533417

  • Cervical extradural meningioma: Case report and literature review JOURNAL OF SPINAL CORD MEDICINE Frank, B. L., Harrop, J. S., Hanna, A., Ratliff, J. 2008; 31 (3): 302-305


    Extradural lesions are most commonly metastatic neoplasms. Extradural meningioma accounts for 2.7 to 10% of spinal neoplasms and most commonly is found in the thoracic spine.Case report.A 45-year-old woman presented with posterior cervicothoracic pain for 8 months following a motor vehicle crash. Magnetic resonance imaging of the cervical spine revealed an enhancing epidural mass. Computerized tomography of the chest, abdomen, and pelvis revealed no systemic disease. Due to the lesion's unusual signal characteristics and location, an open surgical biopsy was completed, which revealed a psammomatous meningioma. Surgical decompression of the spinal cord and nerve roots was then performed. The resection was subtotal due to the extension of the tumor around the vertebral artery.Meningiomas should be considered in the differential diagnosis of contrast-enhancing lesions in the cervical spine.

    View details for Web of Science ID 000258146700009

    View details for PubMedID 18795481

  • Perioperative complications of minimally invasive surgery (MIS): comparison of MIS and open interbody fusion techniques. Surgical technology international Bagan, B., Patel, N., Deutsch, H., Harrop, J., Sharan, A., Vaccaro, A. R., Ratliff, J. K. 2008; 17: 281-286


    The risk of perioperative complications while adopting minimally invasive spine surgery techniques may slow the acceptance of this technology. We assess the perioperative complication rate with minimally invasive single- and two-level interbody fusions and compare this incidence with a contemporaneous cohort of open single- and two-level open interbody fusions, with all procedures completed by a single surgeon in a single practice group. We compiled all open and MIS interbody fusion cases completed during the study period. Sofamor-Danek X-Tube and Stryker Luxor minimally invasive systems were used on all patients. Medical records were reviewed to assess any adverse events occurring in the perioperative period. Care was taken to include all medical and surgical adverse events and complications occurring within 30 days of surgery. Over the study period, 28 minimally invasive lumbar fusions were identified: 24 single- and 4 two-level cases. Both TLIF and PLIF techniques were used. This cohort was compared with a group of 19 single- and two-level open interbody fusion cases completed over the same period. The complication rate for the MIS cohort was 18%, with 7 complications occurring in 5 patients. In the open group, 8 complications occurred in 7 patients, an incidence of 37%. A standard distribution of complications occurred, and the difference between the two groups was not statistically significant. Limiting our analysis to severe complications yielded rates of 7% and 21% for the two groups, also not significantly divergent. Perioperative complications are not more common in well-selected MIS patients. Allowing for proper patient selection, MIS techniques have a favorable complication profile.

    View details for PubMedID 18802914

  • Mortality rates in geriatric patients with spinal cord injuries JOURNAL OF NEUROSURGERY-SPINE Fassett, D. R., Harrop, J. S., Maltenfort, M., Jeyamohan, S. B., Ratliff, J. D., Anderson, D. G., Hilibrand, A. S., Albert, T. J., Vaccaro, A. R., Sraran, A. D. 2007; 7 (3): 277-281


    The authors undertook this study to evaluate the incidence of spinal cord injury (SCI) in geriatric patients (> or = 70 years of age) and examine the impact of patient age, extent of neurological injury, and spinal level of injury on the mortality rate associated with traumatic SCI.A prospectively maintained SCI database (3481 patients) at a single institution was retrospectively studied for the period from 1978 through 2005. Parameters analyzed included patient age, admission American Spinal Injury Association (ASIA) motor score, level of SCI, mechanism of injury, and mortality data. The data pertaining to the 412 patients 70 years of age and older were compared with those pertaining to the younger cohort using a chi-square analysis.Since 1980, the number of SCI-related hospital admissions per year have increased fivefold in geriatric patients and the percentage of geriatric patients within the SCI population has increased from 4.2 to 15.4%. In comparison with younger patients, geriatric patients were found to be less likely to have severe neurological deficits (greater percentage of ASIA Grades C and D injuries), but the mortality rates were higher in the older age group both for the period of hospitalization (27.7% compared with 3.2%, p < 0.001) and during 1-year follow-up. The mortality rates in this older population directly correlate with the severity of neurological injury (1-year mortality rate, ASIA Grade A 66%, Grade D 23%, p < 0.001). The mortality rate in elderly patients with SCI has not changed significantly over the last two decades, and the 1-year mortality rate was greater than 40% in all periods analyzed.Spinal cord injuries in older patients are becoming more prevalent. The mortality rate in this patient group is much greater than in younger patients and should be taken into account when aggressive interventions are considered and in counseling families regarding prognosis.

    View details for Web of Science ID 000249219700003

    View details for PubMedID 17877260

  • The influence of fracture mechanism and morphology on the reliability and validity of two novel thoracolumbar injury classification systems SPINE Whang, P. G., Vaccaro, A. R., Poelstra, K. A., Patel, A. A., Anderson, D. G., Albert, T. J., Hilibrand, A. S., Harrop, J. S., Sharan, A. D., Ratliff, J. K., Hurlbert, R. J., Anderson, P., Aarabi, B., Sekhon, L. H., Gahr, R., Carrino, J. A. 2007; 32 (7): 791-795


    The Thoracolumbar Injury Severity Score (TLISS) and the Thoracolumbar Injury Classification and Severity Score (TLICS) were prospectively evaluated.To compare the reliability and validity of the TLISS and TLICS schemes to determine the importance of injury mechanism and morphology to the identification and treatment of thoracolumbar fractures.Two novel algorithms have been developed for the categorization and management of thoracolumbar injuries: the TLISS system emphasizing injury mechanism and the TLICS scheme involving injury morphology.The clinical and radiographic findings of 25 patients with thoracolumbar fractures were prospectively presented to 5 groups of surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored, first using the TLISS and then 3 months later with the TLICS. The recommended treatments proposed by the 2 schemes were compared with the actual management of each patient.For both algorithms, the interrater kappa statistics of all subgroups (mechanism/morphology, status of the posterior ligaments, total score, predicted management) were within the range of moderate to substantial reproducibility (0.45-0.74), and there were no statistically significant differences noted between the respective kappa values. Interrater correlation was higher for the TLISS paradigm on mechanism/morphology, integrity of the posterior ligaments, and proposed management (P < or = 0.01). The TLISS and TLICS schemes both exhibited excellent overall validity.Although both schemes were noted to have substantial reproducibility and validity, our results indicate the TLISS is more reliable than the TLICS, suggesting that the mechanism of trauma may be a more valuable parameter than fracture morphology for the classification and treatment thoracolumbar injuries. Since these injury characteristics are interrelated and are critical to the maintenance of spinal stability, we think that both concepts should be considered during the assessment and management of these patients.

    View details for Web of Science ID 000245470100014

    View details for PubMedID 17414915

  • Minimally invasive lumbar laminectomy via a dual-tube technique: evaluation in a cadaver model SURGICAL NEUROLOGY Musacchio, M., Patel, N., Bagan, B., Deutsch, H., Vaccaro, A. R., Ratliff, J. 2007; 67 (4): 348-352


    Minimally invasive surgery is a promising new tool in treatment of spinal disorders. Minimally invasive laminectomy provides an efficacious means of achieving lumbar decompression. Present single-tube approaches may entail significant facet injury. We explore the feasibility of a dual-tube minimally invasive laminectomy approach in a cadaver model.We performed minimally invasive lumbar laminectomies in 8 adult cadavers. Twenty-three levels were treated. We used a dual-tube technique, undercutting the facet joints bilaterally while attempting to minimize facet injury. Crossed-tube rongeuring of individual facet joints and neural foramina mirrored open techniques. Pre- and postoperative CT scans of the cadavers were obtained; we measured the cross-sectional area of the spinal canal and neural foramina in each specimen using a CT workstation. Facet damage was assessed. We used the Medtronic Sofamor-Danek (Memphis, Tenn) X-Tube and Quadrant systems to complete individual procedures.Increases in canal cross-sectional area were achieved in each specimen: L3-4 increased from 238.3 to 354.4 mm(2) (125.1%); L4-5, 274 to 390.9 mm(2) (142.7%); and L5-S1, 349.9 mm(2) to 458.8 mm(2) (131%). Neural foraminal diameter also increased in each specimen (L3-4 right increased 123%; left, 136.8%; L4-5, 143.5% and 145.6%; L5-S1, 124% and 116% respectively). Incidental facet injury was noted in 5 (10.9%) of a potential 46 joints.We demonstrate that a dual-tube MIS technique can effectively complete lumbar decompressive laminectomy and foraminotomy procedures in a cadaver model, without significant facet injury. Minimally invasive surgery laminectomy techniques hold significant clinical promise.

    View details for DOI 10.1016/j.surneu.2006.08.075

    View details for Web of Science ID 000245661900005

    View details for PubMedID 17350398

  • Obesity and spine surgery: relation to perioperative complications JOURNAL OF NEUROSURGERY-SPINE Patel, N., Bagan, B., Vadera, S., Maltenfort, M. G., Deutsch, H., Vaccaro, A. R., Harrop, J., Sharan, A., Ratliff, J. K. 2007; 6 (4): 291-297


    Many patients undergoing elective thoracic or lumbar fusion procedures are obese, but the contribution of obesity to complications in spine surgery has not been defined. The authors retrospectively assessed the prevalence of obesity in a cohort of patients undergoing thoracic and lumbar fusion and correlate the presence of obesity with the incidence of operative complications.A retrospective review of consecutive patients treated by a single surgeon (J.K.R.) over a 36-month period at either Rush University Medical Center or the Neurological and Orthopedic Institute of Chicago was performed. The authors identified 332 elective thoracic and lumbar spine surgery cases; the cohort was restricted to include only patients with symptomatic degenerative conditions in need of an anterior, posterior, or combined anterior-posterior fusion. Cases of trauma, tumor, and infection and any case in which the procedure was performed for emergency indications were excluded. A total of 97 cases were identified; of these 86 procedures performed in 84 patients had adequate follow-up material for inclusion in the present study. A broad definition of complications was used. Complications were divided into adverse events (minor) and significant complications (major) based on their impact on patient outcome. Stepwise multivariate logistic regression was used to identify which variables had a significant effect on the risk of complications. Variables considered were body mass index (BMI), height, weight, age, sex, presence or absence of diabetes mellitus (DM) and/or hypertension, number of levels fused (single compared with multiple), and type of surgery performed. The mean BMI for the cohort was 28.8 (95% confidence interval 24.4-30.3); 60 patients (71.4%) were considered overweight or obese (BMI > or = 25). There were 42 complications in 31 patients (36.9%); this included 19 significant complications in 17 patients (20.2%). Logistic regression revealed that the probability of a significant complication was related to BMI (p < 0.04); the chance of a significant complication was 14% with a BMI of 25, 20% with a BMI of 30, and 36% with a BMI of 40. Positioning-related palsies were only found in extremely obese patients (BMI > or = 40). The probability of minor complication occurrence increased with age (p < 0.02), not BMI. The rate of complications was independent of sex as well as the presence of DM or hypertension. A standard collection of complications occurred, including wound infection (three cases), cerebrospinal fluid leakage (eight cases, one requiring reoperation), deep vein thrombosis (two cases), cardiac events (four cases), symptomatic pseudarthrosis (one case), pneumonia (three cases), prolonged intubation (two cases), urological issues (eight cases), positioning-related palsy (two cases), and neuropathic pain (two cases).Obesity is a prevalent condition in patients undergoing elective fusion for degenerative spinal conditions and may increase the prevalence and incidence of perioperative complications. In their analysis, the authors correlated increasing BMI and increased risk of significant postoperative complications. The correlation of obesity and perioperative complications may assist in the preoperative evaluation and selection of patients for surgery.

    View details for Web of Science ID 000245341900001

    View details for PubMedID 17436915

  • Regional variability in use of a novel assessment of thoracolumbar spine fractures: United States versus international surgeons. World journal of emergency surgery : WJES Ratliff, J., Anand, N., Vaccaro, A. R., Lim, M. R., Lee, J. Y., Arnold, P., Harrop, J. S., Rampersaud, R., Bono, C. M., Gahr, R. H. 2007; 2: 24-?


    Considerable variability exists in clinical approaches to thoracolumbar fractures. Controversy in evaluation and nomenclature contribute to this confusion, with significant differences found between physicians, between different specialties, and in different geographic regions. A new classification system for thoracolumbar injuries, the Thoracolumbar Injury Severity Score (TLISS), was recently described by Vaccaro. No assessment of regional differences has been described. We report regional variability in use of the TLISS system between United States and non-US surgeons.Twenty-eight spine surgeons (8 neurosurgeons and 20 orthopedic surgeons) reviewed 56 clinical thoracolumbar injury case histories, which included pertinent imaging studies. Cases were classified and scored using the TLISS system. After a three month period, the case histories were re-ordered and the physicians repeated the exercise; 22 physicians completed both surveys and were used to assess intra-rater reliability. The reliability and treatment validity of the TLISS was assessed. Surgeons were grouped into US (n = 15) and non-US (n = 13) cohorts. Inter-rater (both within and between different geographic groups) and intra-rater reliability was assessed by percent agreement, Cohen's kappa, kappa with linear weighting, and Spearman's rank-order correlation.Non-US surgeons were found to have greater inter-rater reliability in injury mechanism, while agreement on neurological status and posterior ligamentous complex integrity tended to be higher among US surgeons. Inter-rater agreement on management was moderate, although it tended to be higher in US-surgeons. Inter-rater agreement between US and non-US surgeons was similar to within group inter-rater agreement for all categories. While intra-rater agreement for mechanism tended to be higher among US surgeons, intra-rater reliability for neurological status and PLC was slightly higher among non-US surgeons. Intra-rater reliability for management was substantial in both US and non-US surgeons. The TLISS incorporates generally accepted features of spinal injury assessment into a simple patient evaluation tool. The management recommendation of the treatment algorithm component of the TLISS shows good inter-rater and substantial intra-rater reliability in both non-US and US based spine surgeons. The TLISS may improve communication between health providers and may contribute to more efficient management of thoracolumbar injuries.

    View details for PubMedID 17825106

  • Clinical notes - Evaluation of neurologic deficit without apparent cause: The importance of a multidisciplinary approach JOURNAL OF SPINAL CORD MEDICINE Smith, H. E., Rynning, R. E., Okafor, C., Zaslavsky, J., Tracy, J. I., Ratliff, J., Harrop, J., Albert, T., Hilibrand, A., Anderson, G., Sharan, A., Brown, Z., Vaccaro, A. R. 2007; 30 (5): 509-517
  • Minimally invasive thoracolumbar costotransversectomy and corpectomy via a dual-tube technique: evaluation in a cadaver model. Surgical technology international Musacchio, M., Patel, N., Bagan, B., Deutsch, H., Vaccaro, A. R., Ratliff, J. 2007; 16: 221-225


    Minimally invasive surgery (MIS) is a promising new tool in the treatment of a variety of spinal disorders. MIS laminectomy techniques provide an effective means of achieving lumbar decompression. MIS corpectomy techniques have not been described. If feasible, such a technique would be optimal in the treatment of spinal metastatic disease, where traditional open techniques can result in a significant burden to a compromised patient. In this study, we explored the feasibility of a dual-tube minimally invasive thoracic corpectomy approach in a cadaver model. A minimally invasive thoracolumbar costotransversectomy and corpectomy were perfumed in eight adult cadavers. A dual-tube technique was used to perform a costotransversectomy followed by a corpectomy on one side, and through the opposite tube a transpedicular approach on the contralateral side. Pre- and postoperative CT scans of all cadavers were obtained to measure the cross-sectional area of the vertebral bodies in each specimen via a CT workstation. Reconstruction of the anterior column was attempted in some cadavers using polymethylmethacrylate (PMMA) cement. A successful costotransversectomy and corpectomy were completed in each cadaver. A percutaneous delivery system was successful in allowing an anterior column reconstruction using PMMA as a strut graft in selected cadavers. We demonstrated that a dual-tube MIS approach to thoracic corpectomy is technically feasible. Additionally, spinal stabilization can be achieved via percutaneous PMMA administration. This approach may provide a minimally invasive option in the treatment of select spinal metastases.

    View details for PubMedID 17429793

  • Evaluation of neurologic deficit without apparent cause: the importance of a multidisciplinary approach. journal of spinal cord medicine Smith, H. E., Rynning, R. E., Okafor, C., Zaslavsky, J., Tracy, J. I., Ratliff, J., Harrop, J., Albert, T., Hilibrand, A., Anderson, G., Sharan, A., Brown, Z., Vaccaro, A. R. 2007; 30 (5): 509-517


    A patient presenting with an acute neurologic deficit with no apparent etiology presents a diagnostic dilemma. A broad differential diagnosis must be entertained, considering both organic and psychiatric causes.A case report and thorough literature review of acute paraplegia after a low-energy trauma without a discernible organic etiology.Diagnostic imaging excluded any bony malalignment or fracture and any abnormality on magnetic resonance imaging. When no organic etiology was identified, a multidisciplinary approach using neurology, psychiatry, and physical medicine and rehabilitation services was applied. Neurophysiologic testing confirmed the absence of an organic disorder, and at this juncture, diagnostic efforts focused on identifying any psychiatric disorder to facilitate appropriate treatment for this individual. The final diagnosis was malingering.The full psychiatric differential diagnosis should be considered in the evaluation of any patient with an atypical presentation of paralysis. A thorough clinical examination in combination with the appropriate diagnostic studies can confidently exclude an organic disorder. When considering a psychiatric disorder, the differential diagnosis should include conversion disorder and malingering, although each must remain a diagnosis of exclusion. Maintaining a broad differential diagnosis and involving multiple disciplines (neurology, psychiatry, social work, medical specialists) early in the evaluation of atypical paralysis may facilitate earlier diagnosis and initiation of treatment for the underlying etiology.

    View details for PubMedID 18092568

  • Central cord injury: pathophysiology, management, and outcomes. spine journal Harrop, J. S., Sharan, A., Ratliff, J. 2006; 6 (6): 198S-206S


    Cervical spinal trauma can result in a heterogeneous collection of spinal cord injury syndromes. Acute traumatic central cord syndrome is a common category of which no uniform consensus on the etiology, pathophysiology, and treatment exists.To evaluate and review potential pathophysiology, current treatment options, and management of central cord injuries.Comprehensive literature review and clinical experience.A systematic review of Medline for articles related to central cord and spinal cord injury was conducted up to and including journal articles published in September 2005.Central cord injuries is a clinical definition which is composed of a heterogeneous population for which medical management and surgical decompression and stabilization provide improved neurologic recovery.

    View details for PubMedID 17097539

  • An aneurysmal bone cyst in the cervical spine of a 10-year-old girl: A case report SPINE Beiner, J. M., Sastry, A., Berchuck, M., Grauer, J. N., Kwon, B. K., Ratliff, J. K., Stock, G. H., Brown, A. K., Vaccaro, A. R. 2006; 31 (14): E475-E479


    An aneurysmal bone cyst in the neural arch of the fourth cervical vertebra of a 10-year-old girl is reported, along with a brief review of the literature on the topic.To report the presentation and diagnosis of this disorder along with a discussion of the major pitfalls of treatment.An aneurysmal bone cyst occurs commonly in the second decade, with a predilection for the lumbar spine. With occurrence in the neural arch of a cervical vertebra, the potential for instability following surgical excision is high.A 10-year-old white female presented with neck pain of 3 months' duration. Diagnostic imaging revealed an expansile lytic lesion in the spinous process and lamina of the fourth cervical vertebra. Surgical treatment consisted of excisional biopsy and a segmental instrumented posterior fusion from C3-C5. The histopathology was consistent with an aneurysmal bone cyst.Surgical excision consisting of laminectomy and instrumented segmental fusion provided a good clinical result, and minimized the risk and degree of the 2 most common complications: recurrence of the tumor; and postlaminectomy kyphosis, a frequent occurrence in the pediatric population.In pediatric patients who develop a bone tumor of the posterior elements of the cervical spine, careful clinical and radiologic evaluation is necessary to narrow the differential diagnosis. In most cases, a complete excision should be performed if possible. The risk of postlaminectomy kyphosis is high in the pediatric age population. As such, a fusion should be considered whenever a laminectomy is performed in the immature cervical spine. Risk factors for kyphosis include a high cervical level, multiple laminectomy levels, and postoperative irradiation.

    View details for Web of Science ID 000238323700035

    View details for PubMedID 16778679

  • Palsies of the fifth cervical nerve root after cervical decompression: prevention using continuous intraoperative electromyography monitoring JOURNAL OF NEUROSURGERY-SPINE Jimenez, J. C., Sani, S., Braverman, B., DEUTSCH, H., Ratliff, J. K. 2005; 3 (2): 92-97


    A desire to prevent complications resulting from spinal surgery led to the development of intraoperative monitoring. Intraoperative electromyography (EMG) provides useful diagnostic information regarding nerve root function during spinal and peripheral nerve surgeries. The C-5 nerve root is considered particularly vulnerable to injury during cervical surgery. Despite advances in techniques, the incidence of postoperative C-5 palsy has not changed.The authors reviewed prospectively collected data obtained in 161 patients who underwent 171 cervical procedures. In 116 procedures, operative monitoring was modified to include continuous C-5 EMG from the deltoid muscle. In cases in which spontaneous C-5 activity occurred, an appropriate change in operative manipulation was made. A historical control group consisted of a retrospective review of 55 procedures that were monitored using conventional techniques. In the retrospective cohort, four (7.3%) of 55 patients presented after undergoing surgery for C-5 nerve root palsy. In each patient conventional monitoring revealed unremarkable findings. In the prospective cohort, intraoperative spontaneous EMG activity necessitated a change in either positioning or operative technique in three cases. Only one patient (0.9%) experienced postoperative C-5 palsy. Postoperative C-5 palsy occurred in no patient in whom there was no intra-operative evidence of root irritation (p < 0.03, chi-square test).The incidence of postoperative C-5 palsies was reduced from 7.3% to 0.9% due to intraoperative continuous EMG monitoring. No patient suffered a postoperative C-5 palsy when intraoperative evidence of root irritation was absent.

    View details for Web of Science ID 000231368400003

    View details for PubMedID 16370297

  • Metastatic spine tumors SOUTHERN MEDICAL JOURNAL Ratliff, J. K., Cooper, P. R. 2004; 97 (3): 246-253


    Cancer is the second leading cause of death in the United States, and vertebral body metastases often occur in systemic malignancy. Metastatic spinal tumors may present with pain or neurologic deficit, or may be detected during screening examinations in patients with known malignancy. Management of spinal metastases remains controversial. The role of surgery, especially decompressive laminectomy without stabilization, has been questioned. Recent series attest to the beneficial role of surgery, emphasizing anterior and combined decompression and stabilization procedures. We review the relevant literature on metastatic spinal tumors, assessing imaging strategies, adjuvant treatment, patient selection, and results and complications. Operative decompression and stabilization is an important tool in the management of spinal metastatic disease. Patient selection and appropriate use of anterior and/or posterior decompression and stabilization are necessary to optimize surgical results.

    View details for Web of Science ID 000222171900008

    View details for PubMedID 15043331

  • A critical review of cervical laminoplasty NEUROSURGERY QUARTERLY Sani, S., Ratliff, J. K., Cooper, P. R. 2004; 14 (1): 5-16
  • Cervical laminoplasty: a critical review JOURNAL OF NEUROSURGERY Ratliff, J. K., Cooper, P. R. 2003; 98 (3): 230-238


    The technique of cervical laminoplasty was developed to decompress the spinal canal in patients with multi-level anterior compression caused by ossification of the posterior longitudinal ligament or cervical spondylosis. There is a paucity of data confirming its superiority to laminectomy with regard to neurological outcome, preserving spinal stability, preventing postlaminectomy kyphosis, and the development of the "postlaminectomy membrane."The authors conducted a metaanalysis of the English-language laminoplasty literature, assessing neurological outcome, change in range of motion (ROM), development of spinal deformity, and complications. Seventy-one series were reviewed, comprising more than 2000 patients. All studies were retrospective, uncontrolled, nonrandomized case series. Forty-one series provided postoperative recovery rate data in which the Japanese Orthopaedic Association Scale was used for assessing myelopathy. The mean recovery rate was 55% (range 20-80%). The authors of 23 papers provided data on the percentage of patients improving (mean approximately 80%). There was no difference in neurological outcome based on the different laminoplasty techniques or when laminoplasty was compared with laminectomy. There was postlaminoplasty worsening of cervical alignment in approximately 35% and with development of postoperative kyphosis in approximately 10% of patients who underwent long-term follow-up review. Cervical ROM decreased substantially after laminoplasty (mean decrease 50%, range 17-80%). The authors of studies with long-term follow up found that there was progressive loss of cervical ROM, and final ROM similar to that seen in patients who had undergone laminectomy and fusion. In their review of the laminectomy literature the authors could not confirm the occurrence of postlaminectomy membrane causing clinically significant deterioration of neurological function. Postoperative complications differed substantially among series. In only seven articles did the writers quantify the rates of postoperative axial neck pain, noting an incidence between 6 and 60%. In approximately 8% of patients, C-5 nerve root dysfunction developed based on the 12 articles in which this complication was reported.The literature has yet to support the purported benefits of laminoplasty. Neurological outcome and change in spinal alignment are similar after laminectomy and laminoplasty. Patients treated with laminoplasty develop progressive limitation of cervical ROM similar to that seen after laminectomy and fusion.

    View details for Web of Science ID 000181993200001

    View details for PubMedID 12691377

  • Convection-enhanced delivery in intact and lesioned peripheral nerve JOURNAL OF NEUROSURGERY Ratliff, J. K., Oldfield, E. H. 2001; 95 (6): 1001-1011


    Although the use of multiple agents is efficacious in animal models of peripheral nerve injury, translation to clinical applications remains wanting. Previous agents used in trials in humans either engendered severe side effects or were ineffective. Because the blood-central nervous system barrier exists in nerves as it does in the brain, limited drug delivery poses a problem for translation of basic science advances into clinical applications. Convection-enhanced delivery (CED) is a promising adjunct to current therapies for peripheral nerve injury. In the present study the authors assessed the capacity of convection to ferry macromolecules across sites of nerve injury in rat and primate models, examined the functional effects of convection on the intact nerve, and investigated the possibility of delivering a macromolecule to the spinal cord via retrograde convection from a peripherally introduced catheter.The authors developed a rodent model of convective delivery to lesioned sciatic nerves (injury due to crush or laceration in 76 nerves) and compared the results to a smaller series of five primates with similar injuries. In the intact nerve, convective delivery of vehicle generated only a transient neurapraxic deficit. Early after injury (postinjury Days 1, 3, 7, and 10), infusion failed to cross the site of injury in crushed or lacerated nerves. Fourteen days after crush injury, CED of radioactively-labeled albumin resulted in perfusion through the site of injury to distal growing neurites. In primates, successful convection through the site of crush injury occurred by postinjury Day 28. In contrast, in laceration models there was complete occlusion of the extracellular space to convective distribution at the site of laceration and repair, and convective distribution in the extracellular space crossed the site of injury only after there was histological evidence of completion of nerve regeneration. Finally, in two primates, retrograde infusion into the spinal cord through a peripheral nerve was achieved.Convection provides a safe and effective means to deliver macromolecules to regenerating neurites in crush-injured peripheral nerves. Convection block in lacerated and suture-repaired nerves indicates a significant intraneural obstruction of the extracellular space. a disruption that suggests an anatomical obstruction to extracellular and, possibly, intraaxonal flow, which may impair nerve regeneration. Through peripheral retrograde infusion, convection can be used for delivery to spinal cord gray matter. Convection-enhanced delivery provides a promising approach to distribute therapeutic agents to targeted sites for treatment of disorders of the nerve and spinal cord.

    View details for Web of Science ID 000172564600014

    View details for PubMedID 11765815

  • Gunshot wounds to the neck SOUTHERN MEDICAL JOURNAL Tender, G. C., Ratliff, J., Awasthi, D., Buechter, K. 2001; 94 (8): 830-832


    Gunshot wounds to the neck are diagnostically and therapeutically challenging cases. We report such a case with vascular and neurologic injuries and describe the therapeutic options. Initial treatment is aimed at hemodynamic stabilization. Zone II neck injuries are managed selectively, and physical examination alone may dictate emergency surgical exploration. Spinal cord injury must be suspected and assessed clinically, as well as by computed tomography and angiography. Deteriorating or stable neurologic status and cord compression by bullet or bone fragments require surgical decompression. Improving neurologic status may be managed conservatively. In gunshot wounds to the neck, treatment should be individualized and multidisciplinary.

    View details for Web of Science ID 000170847600015

    View details for PubMedID 11549197

  • Root and spinal cord compression from methylmethacrylate vertebroplasty. Spine Ratliff, J., Nguyen, T., Heiss, J. 2001; 26 (13): E300-2


    Case report and literature review.Clinicians use methylmethacrylate vertebroplasty to treat vertebral hemangiomas, metastases, and osteoporotic fractures. Cement may leak out of the vertebral body and compress the adjacent spinal cord and nerve roots. We review a case of nerve-root and cord compression from methylmethacrylate extrusion during vertebroplasty.A 50-year-old female presented with disabling thoracic back pain. A metastasis to T1 was discovered, with collapse of the vertebral body but without cord compression. Methylmethacrylate vertebroplasty was performed. After injection, portable computed tomography (CT) showed a leakage of methylmethacrylate into the C8 and T1 foramina and spinal canal. Radiculopathy and myelopathy developed. Surgical decompression using the anterior approach was necessary.Case report.Early surgical intervention decompressed the neural elements and relieved the neurological deficits.Neurologic complications of methylmethacrylate vertebroplasty necessitate active involvement of spine surgeons in patient evaluation and management.

    View details for PubMedID 11458170

  • Outcome study of surgical treatment for axial neck pain SOUTHERN MEDICAL JOURNAL Ratliff, J., Voorhies, R. M. 2001; 94 (6): 595-602


    We reviewed our surgical treatment of chronic axial cervical pain over a 4-year period to determine whether surgery in selected cases was associated with favorable outcomes.We retrospectively studied 27 consecutive cases (20 patients with follow-up) of longstanding axial cervical spine pain treated surgically by a single surgeon from June 1994 through August 1998. Diagnostic workup included the following when appropriate: Minnesota Multiphasic Personality Inventory (MMPI) with interview, provocative diskography (with a nonpainful control level), single photon emission computed tomography (SPECT), and diagnostic facet injection. Twenty patients (74%) responded to a postoperative telephone survey.For general outcome measures, 85% of patients reported satisfaction with pain relief and surgical result. Ninety-five percent stated they would repeat the procedure; 85% manifested improvement in Prolo score.Surgical treatment of chronic axial neck pain, when preceded by thorough evaluation, can yield excellent clinical results.

    View details for Web of Science ID 000169600400004

    View details for PubMedID 11440327

  • Multiple pituitary adenomas in Cushing's disease JOURNAL OF NEUROSURGERY Ratliff, J. K., Oldfield, E. H. 2000; 93 (5): 753-761


    Clinically evident multiple pituitary adenomas rarely occur. The authors assess the incidence and clinical relevance of multiple adenomas in Cushing's disease.A prospective clinical database of 660 pituitary surgeries was analyzed to assess the incidence of multiple pituitary adenomas in Cushing's disease. Relevant radiographic scans, medical records, and histopathological reports were reviewed. Thirteen patients with at least two separate histopathologically confirmed pituitary adenomas were identified. Prolactinomas (nine patients) were the most common incidental tumors. Other incidental tumors included secretors of growth hormone ([GH], one patient) and GH and prolactin (two patients), and a null-cell tumor (one patient). In two patients, early repeated surgery was performed because the initial operation failed to correct hypercortisolism, in one instance because the tumor excised at the initial surgery was a prolactinoma, not an adrenocorticotropic hormone-secreting tumor. One patient had three distinct tumors.Multiple pituitary adenomas are rare, but may complicate management of patients with pituitary disease.

    View details for Web of Science ID 000090033800004

    View details for PubMedID 11059654

  • Osteochondroma of the C5 lamina with cord compression - Case report and review of the literature SPINE Ratliff, J., Voorhies, R. 2000; 25 (10): 1293-1295


    Case report of a solitary osteochondroma of the cervical spine causing myelopathy in a 66-year-old woman.To review the relevant literature and describe a highly unusual clinical manifestation of solitary osteochondroma.Osteochondromas are common benign bony lesions that seldom occur in the axial skeleton. These lesions are more commonly reported with neural compression in cases of hereditary multiple exostoses (Bessel-Hagel syndrome, diaphyseal aclasis).Chart review, review of relevant radiographic examinations and histopathologic specimens, clinical follow-up with examination, and literature review.Manifestation with new neurologic deficit in a 66-year-old patient was singular.Osteochondromas are unusual in the axial skeleton, and are rarely signaled by neural compression. Occurrence is generally in young adults in the second and third decades. Initial manifestation with a new neurologic deficit in a 66-year-old patient was highly unusual.

    View details for Web of Science ID 000087146200019

    View details for PubMedID 10806510

  • Increased MRI signal intensity in association with myelopathy and cervical instability: Case report and review of the literature SURGICAL NEUROLOGY Ratliff, J., Voorhies, R. 2000; 53 (1): 8-13


    Increased T2-weighted signal intensity in patients with cervical myelopathy has been extensively reviewed in the literature. A variety of etiologies with similar MRI appearances have been described; attempt at correlation of MRI findings with clinical presentation and outcomes after treatment has led to a limited consensus.We present a case of cervical myelopathy with associated hyperintense T2-weighted signal characteristics, secondary to cervical spondylosis and instability.Rapid resolution of radiographic abnormalities after surgical decompression and fusion was noted. Clinical improvement did not parallel radiographic resolution.These findings are important in considering the pathophysiology of MRI changes in cervical myelopathy.

    View details for Web of Science ID 000085420000005

    View details for PubMedID 10697228

  • Tethered cord syndrome in adults SOUTHERN MEDICAL JOURNAL Ratliff, J., Mahoney, P. S., Kline, D. G. 1999; 92 (12): 1199-1203


    Adult onset of tethered cord syndrome is a rare pathologic entity. Its treatable nature makes early diagnosis and timely surgical intervention important goals. Because of present referral patterns, adult patients with tethered cord syndrome may present initially to their primary care physician. We present a recent representative case of adult-onset tethered cord syndrome, with emphasis on initial complaints and the symptom constellation relevant to the primary care physician. Thorough clinical history and physical examination should direct investigators to include tethered cord syndrome in the differential diagnosis of select patients.

    View details for Web of Science ID 000084425200013

    View details for PubMedID 10624914

  • Arteriovenous fistula with associated aneurysms coexisting with dural arteriovenous malformation of the anterior inferior fair - Case report and review of the literature JOURNAL OF NEUROSURGERY Ratliff, J., Voorhies, R. M. 1999; 91 (2): 303-307


    This 24-year-old man presented with an unusual case of a high-flow arteriovenous fistula (AVF). This lesion was similar to giant AVFs in children that have been previously described in the literature. In patients in whom abnormalities of the vein of Galen have been excluded and in whom presentation occurs after 20 years of age, a diagnosis of congenital AVF is quite unusual. The fistula in this case originated in an enlarged callosomarginal artery and drained into the superior sagittal sinus via a saccular vascular abnormality. Two giant aneurysmal dilations of the fistula were present. In an associated finding, a small falcine dural arteriovenous malformation (AVM) was also present. Arterial supply to the AVM arose from both external carotid arteries and the left vertebral artery, with drainage through an aberrant vein in the region of the inferior sagittal sinus into the vein of Galen. Craniotomy with exposure and trapping of the AVF was performed, with subsequent radiosurgical (linear accelerator) treatment of the dural AVM. Through this combination of microsurgical trapping of the AVF and radiotherapy of the dural AVM, an excellent clinical outcome was achieved.

    View details for Web of Science ID 000081681800017

    View details for PubMedID 10433319

  • Intramedullary tuberculoma of the spinal cord - Case report and review of the literature JOURNAL OF NEUROSURGERY Ratliff, J. K., Connolly, E. S. 1999; 90 (1): 125-128


    Intramedullary spinal tuberculosis infection remains an extremely rare disease entity. In the most recent reviews only 148 cases have been reported in the world literature, although numerous recent reports from developing countries and on human immunodeficiency virus (HIV)-positive patients have increased this number. The authors present an unusual case of intramedullary tuberculoma in an HIV-negative patient from the southern United States who demonstrated no other signs or symptoms of tuberculosis infection. The authors believe that this is the first case of its kind to be presented in recent literature. The presentation of miliary disease via an isolated intramedullary spinal mass in a patient with no evident risk factors for tuberculosis infection emphasizes the importance of including tuberculosis in the differential diagnosis of spinal cord masses.

    View details for Web of Science ID 000078774400020

    View details for PubMedID 10413137

  • Management of lumbar instability NEUROSURGERY QUARTERLY Connolly, E. S., Ratliff, J. 1997; 7 (1): 1-10
  • Cholesterol levels in 1,084 healthy New Orleans males. journal of the Louisiana State Medical Society Simopoulos, D. N., Ratliff, J., Elahi, P., Brown, M., Waters, M., McMahon, F. G. 1993; 145 (8): 346-351


    It is widely recognized that elevated cholesterol levels constitute a major risk factor for the development of atherosclerosis and coronary heart disease. Most of the previous surveys conducted in an effort to learn more about incidence of hypercholesterolemia involved patients who had other concurrent risk factors such as hypertension, obesity, diabetes mellitus, cigarette smoking, or a history of myocardial infarction. Relatively few studies have been conducted in younger populations or in healthy individuals. Because we had access to baseline cholesterol data on 1,084 relatively young, otherwise completely healthy, nonobese males, we elected to determine the prevalence of hypercholesterolemia in this population. Elevated cholesterol levels (> 200 mg/dL) were found in 25.2% of our healthy subjects. These findings help to confirm the presence of a potentially serious public health problem existing among otherwise healthy, relatively young men in our community.

    View details for PubMedID 8228545