Try a new search

Format these results:

Searched for:

person:epsten01

in-biosketch:true

Total Results:

71


Anterior cervical surgery for morbidly obese patients should be performed in-hospitals

Epstein, Nancy E.; Agulnick, Marc A.
Background: Morbid obesity (MO) is defined by the World Health Organization (WHO) as Class II (i.e. Body Mass Index (BMI) >/= 35 kg/M2 + 2 comorbidities) or Class III (i.e. BMI >/= 40 kg/M2). Here, we reviewed the rates for adverse event/s (AE)/morbidity/mortality for MO patients undergoing anterior cervical surgery as inpatients/in-hospitals, and asked whether this should be considered the standard of care? Methods: We reviewed multiple studies to document the AE/morbidity/mortality rates for performing anterior cervical surgery (i.e., largely ACDF) for MO patients as inpatients/in-hospitals. Results: MO patients undergoing anterior cervical surgery may develop perioperative/postoperative AE, including postoperative epidural hematomas (PEH), that can lead to acute/delayed cardiorespiratory arrests. MO patients in-hospitals have 24/7 availability of anesthesiologists (i.e. to intubate/run codes) and surgeons (i.e. to evacuate anterior acute hematomas) who can best handle typically witnessed cardiorespiratory arrests. Alternatively, after average 4-7.5 hr. postoperative care unit (PACU) observation, Ambulatory Surgical Center (ASC) patients are sent to unmonitored floors for the remainder of their 23-hour stays, while those in Outpatient SurgiCenters (OSC) are discharged home. Either for ASC or OSC patients, cardiorespiratory arrests are usually unwitnessed, and, therefore, are more likely to lead to greater morbidity/mortality. Conclusion: Anterior cervical surgery for MO patients is best/most safely performed as inpatients/in-hospitals where significant postoperative AE, including cardiorespiratory arrests, are most likely to be witnessed events, and appropriately emergently treated with better outcomes. Alternatively, MO patients undergoing anterior cervical procedures in ASC/OSC will more probably have unwitnessed AE/cardiorespiratory arrests, resulting in poorer outcomes with higher mortality rates. Given these findings, isn't it safest for MO patients to undergo anterior cervical sur er as inpatients/in-hospitals and shouldn't this be considered the standard of care?
SCOPUS:85182646437
ISSN: 2152-7806
CID: 5629172

Anterior cervical surgery for morbidly obese patients should be performed in-hospitals

Epstein, Nancy E; Agulnick, Marc A
BACKGROUND/UNASSIGNED:Morbid obesity (MO) is defined by the World Health Organization (WHO) as Class II (i.e. Body Mass Index (BMI) >/= 35 kg/M2 + 2 comorbidities) or Class III (i.e. BMI >/= 40 kg/M2). Here, we reviewed the rates for adverse event/s (AE)/morbidity/mortality for MO patients undergoing anterior cervical surgery as inpatients/in-hospitals, and asked whether this should be considered the standard of care? METHODS/UNASSIGNED:We reviewed multiple studies to document the AE/morbidity/mortality rates for performing anterior cervical surgery (i.e., largely ACDF) for MO patients as inpatients/in-hospitals. RESULTS/UNASSIGNED:MO patients undergoing anterior cervical surgery may develop perioperative/postoperative AE, including postoperative epidural hematomas (PEH), that can lead to acute/delayed cardiorespiratory arrests. MO patients in-hospitals have 24/7 availability of anesthesiologists (i.e. to intubate/run codes) and surgeons (i.e. to evacuate anterior acute hematomas) who can best handle typically witnessed cardiorespiratory arrests. Alternatively, after average 4-7.5 hr. postoperative care unit (PACU) observation, Ambulatory Surgical Center (ASC) patients are sent to unmonitored floors for the remainder of their 23-hour stays, while those in Outpatient SurgiCenters (OSC) are discharged home. Either for ASC or OSC patients, cardiorespiratory arrests are usually unwitnessed, and, therefore, are more likely to lead to greater morbidity/mortality. CONCLUSION/UNASSIGNED:Anterior cervical surgery for MO patients is best/most safely performed as inpatients/in-hospitals where significant postoperative AE, including cardiorespiratory arrests, are most likely to be witnessed events, and appropriately emergently treated with better outcomes. Alternatively, MO patients undergoing anterior cervical procedures in ASC/OSC will more probably have unwitnessed AE/cardiorespiratory arrests, resulting in poorer outcomes with higher mortality rates. Given these findings, isn't it safest for MO patients to undergo anterior cervical surgery as inpatients/in-hospitals, and shouldn't this be considered the standard of care?
PMCID:10858768
PMID: 38344099
ISSN: 2229-5097
CID: 5635622

Perspective: Efficacy and outcomes for different lumbar interspinous devices (ISD) vs. open surgery to treat lumbar spinal stenosis (LSS)

Epstein, Nancy E; Agulnick, Marc A
BACKGROUND/UNASSIGNED:Interspinous devices (ISD) constitute a minimally invasive (MI) alternative to open surgery (i.e., laminectomy/decompression with/without fusion (i.e., posterior lumbar interbody fusion (PLIF)/posterolateral instrumented fusion (PLF)) for treating lumbar spinal stenosis (LSS). Biomechanically, static and/or dynamic ISD "offload" pressure on the disc space, increase intervertebral foraminal/disc space heights, reverse/preserve lordosis, limit range of motion (ROM)/stabilize the surgical level, and reduce adjacent segment disease (ASD). Other benefits reported in the literature included; reduced operative time (OR Time), length of hospital stay (LOS), estimated blood loss (EBL), and improved outcomes (i.e., ODI (Oswestry Disability Index), VAS (Visual Analog Scale), and/or SF-36 (Short-Form 36)). METHODS/UNASSIGNED:Various studies documented the relative efficacy and outcomes of original (i.e., Wallis), current (i.e., X-STOP, Wallis, DIAM, Aperius PercLID), and new generation (i.e., Coflex, Superion Helifix, In-Space) ISD used to treat LSS vs. open surgery. RESULTS/UNASSIGNED:Although ISD overall resulted in comparable or improved outcomes vs. open surgery, the newer generation ISD provided the greatest reductions in critical cost-saving parameters (i.e., OR time, LOS, and lower reoperation rates of 3.7% for Coflex vs. 11.1% for original/current ISD) vs. original/current ISD and open surgery. Further, the 5-year postoperative study showed the average cost of new generation Coflex ISD/decompressions was $15,182, or $11,681 lower than the average $26,863 amount for PLF. CONCLUSION/UNASSIGNED:Patients undergoing new generation ISD for LSS exhibited comparable or better outcomes, but greater reductions in OR times, EBL, LOS, ROM, and ASD vs. those receiving original/current ISD or undergoing open surgery.
PMCID:10858763
PMID: 38344078
ISSN: 2229-5097
CID: 5635612

Why are spine surgeons sued, and with what outcomes?

Epstein, Nancy E.; Agulnick, Marc A.
Background: Why are spine surgeons sued, how successfully, and for how much? Typical bases for spinal medicolegal suits have included; the failure to timely diagnose and treat, surgical negligence, (i.e. especially resulting in significant neurological deficits), and the lack of informed consent. We reviewed 17 medicolegal spinal articles looking for additional reasons for suits, along with identifying other factors contributing to defense verdicts, plaintiffs' verdicts, or settlements. Methods: After confirming the same three most likely causes of medicolegal suits, other factors leading to such suits included; the lack of patient access to surgeons postoperatively, poor postoperative management (i.e. contributing to new postoperative neurological deficits), failure to communicate between specialists/surgeons perioperatively, and failure to brace. Results: Critical factors leading to more plaintiffs' verdicts and settlements along with higher payouts for both included new severe and/or catastrophic postoperative neurological deficits. Conversely, defense verdicts were more likely for those with less severe new and/or residual injuries. The total number of plaintiffs' verdicts ranged from 17-35.2%, settlements, from 8.3-37%, and defense verdicts from 27.7-75%. Conclusion: The three most frequent bases for spinal medicolegal suits continue to include; failure to timely diagnose/treat, surgical negligence, and lack of informed consent. Here, we identified the following additional causes of such suits; the lack of patient access to surgeons perioperatively, poor postoperative management, lack of specialist/surgeon communication, and failure to brace. Further, more plaintiffs' verdicts or settlements and greater respective payouts were observed for those with new and/or more severe/catastrophic deficits, while more defense verdicts were typically rendered for patients with lesser new neurological injuries.
SCOPUS:85147964251
ISSN: 2152-7806
CID: 5425642

Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored

Epstein, Nancy E.; Agulnick, Marc A.
Background: Patients with postoperative spinal epidural hematomas (pSEH) typically require emergency treatment to avoid paralysis; these hematomas should not be ignored. pSEH patients need to undergo immediate MR studies to document the location/extent of their hematomas, and emergent surgical decompression with/ without fusion if warranted. Methods: THe frequencies of symptomatic pSEH ranged in various series from 0.1%-4.46%. Major predisposing factors included; perioperative/postoperative coagulation abnormalities/disorders, multilevel spine surgeries, previous spine surgery, and intraoperative cerebrospinal fluid (CSF) leaks. For surgery at all spinal levels, one study observed pSEH developed within an average of 2.7 postoperative hours. Another series found 100% of cervical/thoracic, and 50% of lumbar pSEH were symptomatic within 24 postoperative hrs., while a third series noted a 24-48 postoperative window for pSEH to develop. Results: Early recognition of postoperative symptoms/signs of pSEH, warrant immediate MR examinations to diagnose the local/extent of hemorrhages. Subsequent emergent spinal decompressions/fusions are critical to limit/avert permanent postoperative neurological deficits. Additionally, patients undergoing open or minimally invasive spinal procedures where pSEH are suspected, warrant immediate postoperative MR studies. Conclusion: Patients undergoing spinal surgery at any level typically become symptomatic from pSEH within 2.7 to 24 postoperative hours. Early recognition of new neurological deficits, immediate MR studies, and emergent surgery (i.e., if indicated) should limit/minimize postoperative neurological sequelae. THus, pSEH should be treated, not ignored.
SCOPUS:85175479268
ISSN: 2152-7806
CID: 5616482

Perspective: Early direct repair of recurrent postoperative cerebrospinal (CSF) fluid leaks: No good evidence epidural blood patches (EBP) work

Epstein, Nancy E; Agulnick, Marc A
BACKGROUND/UNASSIGNED:"Targeted" epidural blood patches (EBP)" successfully treat "focal dural tears (DT)" diagnosed on thin-cut MR or Myelo-CT studies. These DT are largely attributed to; epidural steroid injections (ESI), lumbar punctures (LP), spinal anesthesia (SA), or spontaneous intracranial hypotension (SICH). Here we asked whether "targeted EBP" could similarly treat MR/Myelo-CT documented recurrent post-surgical CSF leaks/DT that have classically been effectively managed with direct surgical repair. METHODS/UNASSIGNED:Utilizing ultrasound, fluoroscopy, or O-arm guidance, "targeted EBP" effectively manage "focal DT" attributed to ESI, LP, SA, or SICH. Here we reviewed the literature to determine whether similar "targeted EBP" could effectively manage recurrent postoperative CSF leaks/DT. RESULTS/UNASSIGNED:We were only able to identify 3 studies involving just 20 patients that attempted to utilize EBP to control postoperative CSF fistulas/DT. EBP controlled CSF fistulas/DT in 6 patients in the first study, and 9 of 10 patients (i.e. 90%: 2/2 cervical; 7/8 lumbar) in the second study. However, in the third study, 3 (60%) of 5 EBP failed to avert recurrent CSF leaks/DT in 4 patients (i.e. 1 cervical patient (2 EBP failed attempts), 3 lumbar patients (1 failed EBP)). CONCLUSION/UNASSIGNED:Early direct surgical repair of recurrent postoperative spinal CSF leaks/DT remains the treatment of choice. Our literature review revealed 3 underpowered studies including just 20 patients where 20% of EBP failed to control recurrent postoperative fistulas (range of failure from 0-60% per study). Although there are likely other studies we failed to identify in this review, they too are likely insufficiently powered to document significant efficacy for performing EBP over direct surgical repair for recurrent postoperative CSF leaks/DT.
PMCID:10159275
PMID: 37151440
ISSN: 2229-5097
CID: 5544452

Perspective; high frequency of intraoperative errors due to extreme, oblique, and lateral lumbar interbody fusions (XLIF, OLIF, LLIF): Are they "safe"?

Epstein, Nancy E; Agulnick, Marc A
BACKGROUND/UNASSIGNED:Extreme Lateral Lumbar Interbody Fusions (XLIF), Oblique Lateral Interbody Fusion (OLIF,) and Lateral Lumbar Interbody Fusion (LLIF) were largely developed to provide indirect lumbar decompressions for spinal stenosis, deformity, and/or instability. METHODS/UNASSIGNED:Here, we have reviewed and updated the incidence of intraoperative errors attributed to XLIF, OLIF, and LLIF. Specifically, we focused on how often these procedures caused new neurological deficits, major vessel, visceral, and other injuries, including those warranting secondary surgery. RESULTS/UNASSIGNED:Performing XLIF, OLIF, and LLIF can lead to significant intraoperative surgical errors that include varying rates of; new neurological injuries (i.e. iliopsoas motor deficits (4.3-19.7-33.6-40%), proximal hip/upper thigh sensory loss/dysesthesias (5.1% to 21.7% to 40%)), life-threatneing vascular injuries (i.e., XLIF (0% - 0.4%-1.8%), OLIF (3.2%), and LLIF (2%) involving the aorta, iliac artery, inferior vena cava, iliac vein, and segmental arteries), and bowel/viscarl injuries (0.03%-0.4%) leading to reoperations (i.e., XLIF (1.8%) vs. LLIF (3.8%) vs. XLIF/LLIF/OLIF 2.2%)). CONCLUSION/UNASSIGNED:Varying reports documented that XLIF, OLIF and LLIF caused up to a 40% incidence of new sensory/motor deficits, up to a 3.2% incidence of major vascular insults, a 0.4% frequency of visceral/bowel perforations, and a 3.8% need for reoperations. These high frequencies of intraoperative surgical errors attributed to XLIF, OLIF, and LLIF should prompt reconsideration of whether these procedures are "safe."
PMCID:10559463
PMID: 37810305
ISSN: 2229-5097
CID: 5604522

Cervical disc arthroplasty (CDA)/total disc replacement (TDR) vs. anterior cervical diskectomy/fusion (ACDF): A review

Epstein, Nancy E.; Agulnick, Marc A.
Background: We performed a focused review to determine the "non-inferiority", potential superiority, and relative safety/efficacy for performing cervical disc arthroplasty (CDA)/total disc replacement (TDR) in carefully selected patients vs. anterior cervical diskectomy/fusion (ACDF). Notably, CDA/TDR were devised to preserve adjacent level range of motion (ROM), reduce the incidence of adjacent segment degeneration (ASD), and the need for secondary ASD surgery. Methods: We compared the incidence of ASD, reoperations for ASD, safety/efficacy, and outcomes for cervical CDA/TDR vs. ACDF. Indications, based upon the North American Spine Society (NASS) Coverage Policy Recommendations (Cervical Artificial Disc Replacement Revised 11/2015 and other studies) included the presence of radiculopathy or myelopathy/myeloradiculopathy at 1-2 levels between C3-C7 with/without neck pain. Contraindications for CDA/TDR procedures as quoted from the NASS Recommendations (i.e. cited above) included the presence of; "Infection ", "Osteoporosis and Osteopenia", "Instability ", "Sensitivity or Allergy to Implant Materials", "Severe Spondylosis ", "Severe Facet Joint Arthropathy ", "Ankylosing Spondylitis"(AS), "Rheumatoid Arthritis (RA), Previous Fracture ", "Ossification of the Posterior Longitudinal Ligament (OPLL)", and "Malignancy ". Other sources also included spinal stenosis and scoliosis. Results: Cervical CDA/TDR studies in the appropriately selected patient population showed no inferiority/ occasionally superiority, reduced the incidence of ASD/need for secondary ASD surgery, and demonstrated comparable safety/efficacy vs. ACDF. Conclusion: Cervical CDA/TDR studies performed in appropriately selected patients showed a "lack of inferiority", occasional superiority, a reduction in the incidence of ASD, and ASD reoperation rates, plus comparable safety/efficacy vs. ACDF.
SCOPUS:85146708467
ISSN: 2152-7806
CID: 5423802

Review of anterior cervical diskectomy/fusion (ACDF) using different polyetheretherketone (PEEK) cages

Epstein, Nancy E.; Agulnick, Marc A.
Background: Multiple anterior cervical diskectomy/fusion (ACDF) techniques now use a variety of Polyehteretherketone (PEEK) cages; stand-alone (SA) and zero-profile (ZP) with/without screws, cages filled with demineralized bone matrix/autograft, and cages coated with hydroxyapatite or titanium. We compared the safety/ efficacy between different PEEK ACDF cage constructs in 17 studies, and in some cases, additionally contrasted results with "routine"ACDF (i.e. series/historical data performed with combinations of iliac autograft/allograft and plates). Methods: We focused on the clinical outcomes, fusion rates, postoperative radiographic changes/lordosis/ subsidence, and/or reoperation rates for various PEEK ACDF constructs vs. "routine"ACDF. Results: One to 3 and 4-level PEEK ACDF cages demonstrated high fusion rates, few cage failures, and low reoperation rates. Subsidence for PEEK ACDF cages did not reduce fusion rates or diminish the quality of postoperative outcomes. Further, titanium-coated (T-C) PEEK cages lowered fusion rates in one study (i.e. 44.1% fusions vs. 88.2% for routine PEEK ACDF) while ACDF PEEK cages coated with hydroxyapatite (HA) showed only a "trend"toward enhanced arthrodesis. Conclusion: One to 3-4 multilevel ACDF PEEK cage constructs demonstrated comparable safety/efficacy when compared with each other, or in select cases, with "routine"ACDF (i.e. using autograft/allograft and plates).
SCOPUS:85146714609
ISSN: 2152-7806
CID: 5423812

Short Review/Perspective on Adjacent Segment Disease (ASD) Following Cervical Fusion Versus Arthroplasty

Epstein, Nancy E; Agulnick, Marc A
Background/UNASSIGNED:Although the incidence of radiographic Adjacent Segment Disease (ASD) following anterior cervical diskectomy/fusion (ACDF) or cervical disc arthroplasty (CDA) typically ranges from 2-4%/year, reportedly fewer patients are symptomatic, and even fewer require secondary surgery. Methods/UNASSIGNED:Multiple studies have documented a 2-4% incidence of radiographic ASD following either ACDF or CDA per year. However, fewer are symptomatic from ASD, and even fewer require additional surgery/reoperations. Results/UNASSIGNED:In a meta-analysis (2016) involving 83 papers, the incidence of radiographic ASD per year was 2.79%, but symptomatic disease was present in just 1.43% of patients with only 0.24% requiring secondary surgery. In another study (2019) involving 38,149 patients undergoing ACDF, 2.9% (1092 patients; 0.62% per year) had radiographic ASD within an average of 4.66 postoperative years; the younger the patient at the index surgery, the higher the reoperation rate (i.e. < 40 years of age 4.56 X reoperations vs. <70 at 2.1 X reoperations). In a meta-analysis of 32 articles focusing on ASD 12-24 months following CDA, adjacent segment degeneration (ASDeg) occurred in 5.15% of patients, but adjacent segment disease (AS Dis) was noted in just 0.2%/ year. Further, AS degeneration occurred in 7.4% of patients after 1-level vs. 15.6% following 2 level fusions, confirming that CDA's "motion-sparing" design did not produce the "anticipated" beneficial results. Conclusion/UNASSIGNED:The incidence of radiographic ASD ranges from 2-4% per year for ACDF and CDA. Additionally, both demonstrate lesser frequencies of symptomatic ASD, and the need for secondary surgery. Further, doubling the frequency of ASD following 2 vs. 1-level CDA, should prompt surgeons to limit surgery to only essential levels.
PMCID:9345126
PMID: 35928322
ISSN: 2229-5097
CID: 5288282