The history of neurosurgery at Baylor College of Medicine.

The development of neurosurgery at Baylor College of Medicine began with the medical school's relocation to the new Texas Medical Center in Houston in 1943. An academic service was organized in 1949 as a section of neurosurgery within Baylor's Department of Surgery. Soon the practice, led by Dr. George Ehni, evolved to include clinical services at Methodist, Jefferson Davis (forerunner of Ben Taub), Texas Children's, the Veterans Affairs, and the University of Texas MD Anderson Cancer Center hospitals. A neurosurgery residency program was established in 1954. As the clinical practice expanded, neurosurgery was upgraded from a section to a division and then to a department. It has been led by four chiefs/chairs over the past 60 years-Dr. George Ehni (1959-1979), Dr. Robert Grossman (1980-2004), Dr. Raymond Sawaya (2005-2014), and Dr. Daniel Yoshor (2015-2020). Since the 1950s, the department has drawn strength from its robust residency program, its research base in the medical school, and its five major hospital affiliates, which have largely remained unchanged (with the exception of Baylor St. Luke's Medical Center replacing Methodist in 2004). The recent expansion of the residency program to 25 accredited positions and the growing strength of relationships with the "Baylor five" hospitals affiliated with Baylor College of Medicine portend a bright future.

Association of Airborne Microorganisms in the Operating Room With Implant Infections: A Randomized Controlled Trial.

OBJECTIVE To evaluate the association of airborne colony-forming units (CFU) at incision sites during implantation of prostheses with the incidence of either incisional or prosthesis-related surgical site infections. DESIGN Randomized, controlled trial. SETTING Primary, public institution. PATIENTS Three hundred patients undergoing total hip arthroplasty, instrumented spinal procedures, or vascular bypass graft implantation. METHODS Patients were randomly assigned in a 1:1 ratio to either the intervention group or the control group. A novel device (Air Barrier System), previously shown to reduce airborne CFU at incision sites, was utilized in the intervention group. Procedures assigned to the control group were performed without the device, under routine operating room atmospheric conditions. Patients were followed up for 12 months to determine whether airborne CFU levels at the incision sites predicted the incidence of incisional or prosthesis-related infection. RESULTS Data were available for 294 patients, 148 in the intervention group and 146 in the control group. CFU density at the incision site was significantly lower in the intervention group than in the control group (P<.001). The density of airborne CFU at the incision site during the procedures was significantly related to the incidence of implant infection (P=.021). Airborne CFU densities were 4 times greater in procedures with implant infection versus no implant infection. All 4 of the observed prosthesis infections occurred in the control group. CONCLUSION Reduction of airborne CFU specifically at the incision site during operations may be an effective strategy to reduce prosthesis-related infections. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01610271 Infect Control Hosp Epidemiol 2016;1-8.

Outcomes of a novel minimalist approach for the treatment of cubital tunnel syndrome.

We describe a minimalist approach to perform in situ decompression of the ulnar nerve. Our technique employs a unique small skin incision strategically placed to minimize postoperative scarring over the ulnar nerve and potentially decrease the risk of iatrogenic injury to the medial antebrachial cutaneous nerve. We retrospectively report the outcome of patients who have undergone this procedure at our institution, the Michael E. DeBakey Veterans Affairs Medical Center, from January 1 2007 through November 29 2010. All individuals underwent in situ decompression via the previously described minimalist approach. Outcome variables were Louisiana State University Medical Center (LSU) ulnar neuropathy grade, patient satisfaction, subjective improvement, complications and re-operation rate. A total of 44 procedures were performed in this cohort of 41 patients. Overall, patients' postoperative LSU grades showed a statistically significant improvement (p=0.0019) compared to preoperative grades. Improvement of at least one grade in the LSU scale was observed in 50% of the procedures with a preoperative grade of four or less. Overall procedure satisfaction rate was 88% (39 of 44) with 70% (31 of 44) of the procedures resulting in improvement of symptoms. There were no intraoperative or postoperative complications. One patient required re-operation due to failure of neurological improvement. Our minimalistic approach to perform in situ decompression of the ulnar nerve at the cubital tunnel is both safe and effective. We observed a statistically significant improvement in LSU ulnar neuropathy grades and a success rate comparable to those reported for other more extensive surgical techniques while providing the benefit of a smaller incision, less scarring, decreased risk of iatrogenic nerve injury and minimal complications.

In vitro biomechanical evaluation of single impulse and repetitive mechanical shockwave devices utilized for spinal manipulative therapy.

Mechanical shockwave therapy devices have been in clinical use for almost 40 years. While most often used to treat back pain, our understanding of their biomechanical performance is very limited. From biomechanical studies we know that biological tissue is viscoelastic and preferably excited around its resonance frequency. Targeting these frequencies has been the focus in extracorporeal shock wave lithotripsy, but these concepts are relatively new in orthopedic and rehabilitation therapies. The exact mechanism by which shockwave therapy acts is not known. Knowledge of the performance characteristics of these devices, correlated with clinical outcome studies, may lead to better patient selection, improvement of device functionality, and knowledge of the underlying working principals of therapy. The objectives of this study were to determine the ability of several commercial shockwave devices to achieve a desired thrust profile in a benchtop setting, determine the thrust profile in a clinical analog, and determine the influence of operator experience level on device performance. We conducted two different types of testing: (1) bench testing to evaluate the devices themselves, and (2) clinical equivalent testing to determine the influence of the operator. The results indicated a significant dependence of thrust output on the compliance of the test media. The Activator V-E device matched the ideal half-sine thrust profile to 94%, followed by the Impulse device (84%), the Activator IV/FS (74%), and the Activator II (48%). While most devices deviated from the ideal profile on the return path, the Impulse device exhibited a secondary peak. Moreover, the Activator V-E device provided evidence that the device performs consistently despite operator experience level. This has been a major concern in manual spinal manipulation. Based on our results, a hyper-flexible spine would receive a lower peak thrust force than a hypo-flexible spine at the same power setting. Furthermore, a hand-held operation further reduced the peak thrust force as it increased the system compliance. However, that influence was dissimilar for the different devices. Although controlled clinical trials are needed to determine the correlation between thrust profile and clinical outcome, already ongoing clinical studies indicate an improved patient satisfaction due to reduced treatment pain when devices are used with a thrust characteristic closer to an ideal sine wave.

Spontaneous resolution of spinal epidural lipomatosis.

Spinal epidural lipomatosis (SEL) is an abnormal accumulation of unencapsulated, epidural fat. SEL can be divided into idiopathic and secondary. Secondary SEL is often associated with chronic steroid use and endocrinopathies. Idiopathic SEL has been associated with obesity. SEL has been implicated in a variety of neurologic impairments and surgical decompression has been shown to prevent further worsening or result in improvement. We report a 53-year-old man with obesity and a history of chronic back pain who developed idiopathic SEL diagnosed by MRI, which subsequently resolved completely over an 8 month follow-up period. To our knowledge, this is the first reported case of complete radiographic resolution of SEL without any treatment.

A national fundamentals curriculum for neurosurgery PGY1 residents: the 2010 Society of Neurological Surgeons boot camp courses.

BACKGROUND: In July 2009, the Accreditation Council for Graduate Medical Education (ACGME) incorporated postgraduate year 1 (PGY1 intern) level training into all U.S. neurosurgery residency programs. OBJECTIVE: To provide a fundamentals curriculum for all incoming neurosurgery PGY1 residents in ACGME-accredited programs, including skills, knowledge, and attitudes that promote quality, patient safety, and professionalism. METHODS: The Society of Neurological Surgeons organized 6 regional "boot camp" courses for incoming neurosurgery PGY1 residents in July 2010 that consisted of 9 lectures on clinical and nonclinical competencies plus 10 procedural and 6 surgical skills stations. Resident and faculty participants were surveyed to assess knowledge and course effectiveness. RESULTS: A total of 186 of 197 U.S. neurosurgical PGY1 residents (94%) and 75 neurosurgical faculty from 36 of 99 programs (36%) participated in the inaugural boot camp courses. All residents and 83% of faculty participants completed course surveys. All resident and faculty respondents thought that the boot camp courses fulfilled their purpose and objectives and imparted skills and knowledge that would improve patient care. PGY1 residents' knowledge of information taught in the courses improved significantly in postcourse testing (P < .0001). Residents and faculty particularly valued simulated and other hands-on skills training. CONCLUSION: Regional organization facilitated an unprecedented degree of participation in a national fundamental skills program for entering neurosurgery residents. One hundred percent of resident and faculty respondents positively reviewed the courses. The boot camp courses may provide a model for enhanced learning, professionalism, and safety at the inception of training in other procedural specialties.

Premature adjacent vertebral fracture after vertebroplasty: a biomechanical study.

BACKGROUND: There is an increased incidence of fractures in untreated adjacent vertebrae after vertebroplasty. OBJECTIVE: To introduce unconstrained 6 degrees of freedom biomechanical testing to investigate whether vertebroplasty lowered the fracture strength of adjacent untreated vertebrae under physiological loading conditions and to describe the observed fracture pattern. METHODS: Three-level spinal segments (T10-12 and L1-3) from 6 spines were tested under unconstrained axial compression in which shear forces and torque were minimized using a 6-degrees of freedom robotic arm. Fracture initiation loads and ultimate failure loads of lumbar segments were predicted from the corresponding thoracic segments by assuming constant fracture stress along the spinal column. The predicted values were compared with postvertebroplasty experimental values of the lumbar spine segments. Plain radiographs were taken at 600-N increments to record the developing fracture pattern. RESULTS: All 6 vertebroplasty group specimens experienced reductions in fracture strengths ranging from 27.4% to 47.6% with an average decrease of 32.6% (P < .002) and reductions in ultimate failure load ranging from 1.6% to 47.3%, with an average decrease of 34.7% (P < .003) compared with predicted values from the nonvertebroplasty group. In all vertebroplasty group specimens, the superior and inferior endplates of the untreated middle vertebral body (L2) were deflected, whereas 5 of the 6 nonvertebroplasty group specimens did not show any evidence of endplate deflection. CONCLUSION: Vertebroplasty altered the load transfer along the anterior spinal column, thereby statistically significantly increasing fracture risk and ultimate failure load of the untreated adjacent vertebrae. The radiographic findings support the endplate deflection fracture mechanism as the cause of adjacent fractures after vertebroplasty.

False-positive indium 111 pentetreotide scan for recurrent meningioma due to radiation fibrosis.

A patient with recurrent meningioma in the right frontal lobe, treated with resection and radiation, had a routine magnetic resonance imaging scan that was suspicious for recurrent disease. Follow-up Octreoscan showed moderately increased focal uptake in same region, compatible with recurrence of meningioma; however, the histopathology was consistent with radiation fibrosis. There are reported cases of uptake on Octreoscans at other sites of the body due to chronic inflammation, but only one other case has been reported in the brain. Caution must be taken in interpretation of brain tumors on Octreotide scan, when treatment history includes prior radiation therapy.

Vacuum-assisted en bloc resection of large convexity meningiomas. Technical note.

Convexity meningiomas are common tumors encountered by neurosurgeons. Retracting, grasping, and mobilizing large convexity meningiomas can be difficult and awkward as well as place unwanted forces on surrounding neurovascular structures. The authors present a safe alternative to traditional retraction and manipulation methods by using a modified bulb syringe connected to standard surgical suction to function as a vacuum retractor. This technique allows for rapid, safe, en bloc resection of large convexity meningiomas with little to no pressure on the surrounding brain. The authors present an illustrative case and describe and discuss the technique.

Minimalist cubital tunnel treatment.

OBJECTIVE: The surgical treatment of cubital tunnel syndrome by various techniques is often met with disappointing results. An optimal treatment is not agreed upon. The authors propose a collection of techniques which they believe optimizes outcome and minimizes iatrogenic injuries. METHODS: A combination of a novel skin incision which minimizes scar and iatrogenic cutaneous nerve injury, a technique of in situ decompression, and an atraumatic technique of ensuring complete nerve exploration proximal and distal to the incision is presented; these methods have been in use by the senior author for a number of years. RESULTS: Numerous reports have demonstrated that the success of in situ ulnar nerve release by division of Osborne's fascia is equivalent to the success rates of more invasive operations for the condition of ulnar neuropathy. The authors share this view in the majority of cases of ulnar neuropathy, and they present a technique that can be expanded, if necessary, on the basis of surgical findings, with only a few indications for the greater epicondylectomy or transposition procedures. CONCLUSION: The authors present a means of treating cubital tunnel syndrome. Failure of in situ cubital tunnel release, as with failure of any ulnar procedure, can be attributed to intraoperative ulnar nerve injury, injury to the medial antebrachial cutaneous nerve, inadequate longitudinal exploration and release, scar formation with recurrent compression and/or traction, and the possibility that decompression could lead to iatrogenic symptomatic nerve subluxation. The authors discuss the rationale for a minimalist open surgical approach for the treatment of cubital tunnel syndrome, and each of these concerns is addressed.

A supratentorial, hemorrhagic, intraparenchymal epidermoid cyst.

Epidermoid cysts are slow growing benign tumors that represent < 1-2% of all intracranial tumors and rarely present as supratentorial, intraparenchymal masses. We present the first report of a supratentorial, hemorrhagic, intraparenchymal epidermoid cyst with its presentation, our operative approach, post-operative course, radiographic features, and a literature review.