James M Schuster

Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (26)47.64 Total impact

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    ABSTRACT: Background:Venous thromboembolic prophylaxis (VTEp) is often delayed following traumatic brain injury (TBI), yet animal data suggest that it may reduce cerebral inflammation and improve cognitive recovery. We hypothesized that earlier VTEp initiation in severe TBI patients would result in more rapid neurologic recovery and reduced progression of brain injury on radiologic imaging.Study Design:Medical charts of severe TBI patients admitted to a level 1 trauma center in 2009-2010 were queried for admission Glasgow Coma Scale (GCS), head Abbreviated Injury Scale, Injury Severity Score (ISS), osmotherapy use, emergency neurosurgery, and delay to VTEp initiation. Progression (+1 = better, 0 = no change, −1 = worse) of brain injury on head CTs and neurologic exam (by bedside MD, nurse) was collected from patient charts. Head CT scan Marshall scores were calculated from the initial head CT results.Results:A total of 22, 34, and 19 patients received VTEp at early (<3 days), intermediate (3-5 days), and late (>5 days) time intervals, respectively. Clinical and radiologic brain injury characteristics on admission were similar among the three groups (P > 0.05), but ISS was greatest in the early group (P < 0.05). Initial head CT Marshall scores were similar in early and late groups. The slowest progression of brain injury on repeated head CT scans was in the early VTEp group up to 10 days after admission.Conclusion:Early initiation of prophylactic heparin in severe TBI is not associated with deterioration neurologic exam and may result in less progression of injury on brain imaging. Possible neuroprotective effects of heparin in humans need further investigation.
    Journal of Emergencies Trauma and Shock 03/2014; 7(3):141-148. DOI:10.4103/0974-2700.136846
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    ABSTRACT: Spondylopelvic dissociation is a complex injury pattern resulting in multiplanar instability of the lumbopelvis. These injuries have traditionally been known as "suicide jumper's fractures" and have recently increased in prevalence as a result of under-vehicle explosions seen in the past decade of military conflicts in the Middle East. The hallmarks of spondylopelvic dissociation are bilateral vertical sacral fractures with a horizontal component, resulting in lumbosacral instability in the sagittal and axial planes. Surgical treatment has evolved greatly and both percutaneous and open options are available, with triangular osteosynthesis being the most relied on method of fixation.
    Orthopedic Clinics of North America 01/2014; 45(1):65-75. DOI:10.1016/j.ocl.2013.08.002 · 1.70 Impact Factor
  • Leif-Erik Bohman, James M Schuster
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    ABSTRACT: Decompressive craniectomy (DC) for the management of severe traumatic brain injury (TBI) has a long history but remains controversial. Although DC has been shown to improve both survival and functional outcome in patients with malignant cerebral infarctions, evidence of benefit in patients with TBI is decidedly more mixed. Craniectomy can clearly be life-saving in the presence of medically intractable elevations of intracranial pressure. Craniectomy also has been consistently demonstrated to reduce "therapeutic intensity" in the ICU, to reduce the need for intracranial-pressure-directed and brain-oxygen-directed interventions, and to reduce ICU length of stay. Still, the only randomized trial of DC in TBI failed to demonstrate any benefit. Studies of therapies for TBI, including hemicraniectomy, are challenging owing to the inherent heterogeneity in the pathophysiology observed in this disease. Craniectomy can be life-saving for patients with severe TBI, but many questions remain regarding its ideal application, and the outcome remains highly correlated with the severity of the initial injury.
    Current Neurology and Neuroscience Reports 11/2013; 13(11):392. DOI:10.1007/s11910-013-0392-x · 3.67 Impact Factor
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    ABSTRACT: Study Design Systematic review. Study Rationale One of the most consistent indications for a Chiari decompression is tonsillar descent meeting the radiographic criteria and an associated syrinx in a symptomatic patient. In counseling patients about surgery, it would be advantageous to have information regarding the expected outcome with regard to the syrinx and other possible treatments available if the result is suboptimal. Clinical Questions The clinical questions include: (1) What is the average rate of recurrent or residual syringomyelia following posterior fossa decompression as a result of Chiari malformation with associated syringomyelia? (2) What treatment methods have been reported in the literature for managing recurrent or residual syringomyelia after initial posterior fossa decompression? Materials and Methods Available search engines were utilized to identify publications dealing with recurrent or residual syrinx after Chiari decompression and/or management of the syrinx. Rates of residual or recurrent syrinx were extracted and management strategies were recorded. Overall strength of evidence was quantified. Results Of the 72 citations, 11 citations met inclusion criteria. Rates of recurrent/residual syringomyelia after decompression in adults range from 0 to 22% with an average of 6.7%. There were no studies that discussed specifically management of the remaining syrinx. Conclusion Rates of recurrent/residual syringomyelia after Chiari decompression in adults range from 0 to 22% (average 6.7%). Although no studies describing the optimal management of residual syrinx were found, there is general agreement that the aim of the initial surgery is to restore relatively unimpeded flow of cerebrospinal across the craniocervical junction. Large holocord syrinx may induce a component of spinal cord injury even with adequate decompression and reduction in the caliber of the syrinx, resulting in permanent symptoms of injury.
    10/2013; 4(2):116-125. DOI:10.1055/s-0033-1357362
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    ABSTRACT: Object Gunshot wounds to the atlantoaxial spine are uncommon injuries and rarely require treatment, as a bullet traversing this segment often results in a fatal injury. Additionally, these injuries are typically biomechanically stable. The authors report a series of 10 patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex. Their care is discussed and conclusions are drawn from these cases to identify the optimal treatment for these injuries. Methods A retrospective review was conducted of patients presenting to the emergency rooms of 3 institutions with gunshot wounds involving the atlantoaxial spine. Mechanism of injury and neurological status were obtained, as was the extent of the osteoligamentous, vascular, and neurological injuries. Nonoperative and operative treatment, complications, and clinical and radiographic outcome were recorded. The data were then analyzed to determine the neurological and biomechanical prognosis of these injuries, the utility of the various diagnostic modalities in the acute management of the injuries, and the nature and effectiveness of the nonoperative and operative treatment modalities. Results Ten patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex were identified. All but 2 patients sustained a vertebral artery injury. Each patient was evaluated using cervical radiographs, CT scans, and vascular imaging, 8 in the form of digital subtraction angiography and 2 with high-resolution CT angiography. Uncomplicated patients were treated conservatively using cervical collar immobilization, local wound care, and antibiotics. One patient was treated using a halo for instability and 1 underwent posterior fusion following a posterolateral decompression for delayed myelopathy. One patient underwent transoral resection of a bullet fragment. One patient underwent embolization for a symptomatic arteriovenous fistula and a second patient underwent a neck exploration and a jugular vein ligation. None of the patients received anticoagulation therapy. The mean follow-up duration was 13 months. All but 2 patients regained their previous functional status and all ultimately attained a mechanically stable spine. Conclusions These 10 patients represent a rare form of cervical spine penetrating injury. Unilateral gunshot wounds to the atlantoaxial complex are usually stable and the need for acute surgical intervention is rare. Unilateral vertebral artery injury is well tolerated and any information provided by angiography does not alter the acute management of the patient. Vascular complications from gunshot wounds can be managed effectively by endovascular techniques.
    Journal of neurosurgery. Spine 09/2013; 19(6). DOI:10.3171/2013.8.SPINE12907 · 2.36 Impact Factor
  • 01/2013; 02(01). DOI:10.4172/2325-9701.1000106
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    ABSTRACT: OBJECTIVE: Intramedullary spinal sarcoidosis is a difficult diagnosis to make because of its non-specific clinical and imaging features and its imitation of other common spine disorders. We present a patient with intramedullary spinal sarcoidosis that mimicked spinal cord injury from a cervical disk herniation. METHODS: Relevant information was extracted from the patient's medical and imaging records. A thorough literature review subsequently was performed. RESULTS: A 59-year-old woman presented to our institution with several months of intermittent parathesias, pain, and subjective weakness in her right upper and lower extremities. Magnetic resonance imaging (MRI) of the cervical spine demonstrated a large osteophyte-disc complex at C4-5 adjacent to a small area of intramedullary spinal cord enhancement. The patient underwent C4-5 anterior cervical diskectomy and fusion for the osteophyte-disc complex. She initially improved post-operatively but subsequently declined after a couple of months. Because of more prominent spinal cord enhancement, a posterior laminectomy and biopsy of the enhancing lesion was performed. Intramedullary spinal sarcoidosis was diagnosed, and she was treated medically with steroids and immunosuppressive agents. CONCLUSION: Spinal sarcoidosis can mimic more common disease processes, such as cervical spondylosis. It is an important consideration in the diagnosis of intramedullary or intradural lesions of the spinal cord because early medical treatment may improve the course of the disease process. Surgery should be limited to biopsy for diagnostic purposes.
    World Neurosurgery 10/2012; 80(6). DOI:10.1016/j.wneu.2012.09.022 · 2.42 Impact Factor
  • Journal of the American College of Surgeons 09/2012; 215(3):S54. DOI:10.1016/j.jamcollsurg.2012.06.158 · 4.45 Impact Factor
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    ABSTRACT: 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. 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. 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. 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. 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.
    Neurosurgery 10/2011; 70(4):971-81; discussion 981. DOI:10.1227/NEU.0b013e31823d7a45 · 3.03 Impact Factor
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    ABSTRACT: Systematic review of literature focused on heterogeneity of treatment effect analysis. The objectives of this systematic review were to determine if comorbid disease and general health factors modify the effect of fusion versus nonoperative management in chronic low back pain (CLBP) patients? Surgical fusion as a treatment of back pain continues to be controversial due to inconsistent responses to treatment. The reasons for this are multifactorial but may include heterogeneity in the patient population and in surgeon's attitudes and approaches to this complex problem. There is a relative paucity of high quality publications from which to draw conclusions. We were interested in investigating the possibility of detecting treatment response differences comparing fusion to conservative management for CLBP among subpopulations with different disease specific and general health risk factors. A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for literature published from 1990 through December 2010. To evaluate whether the effects of CLBP treatment varied by disease or general health subgroups, we sought randomized controlled trials or nonrandomized observational studies with concurrent controls evaluating surgical fusion versus nonoperative management for CLBP. Of the original 127 citations identified, only 5 reported treatment effects (fusion vs. conservative management) separately by disease and general health subgroups of interest. Of those, only two focused on patients who had primarily back pain without spinal stenosis or spondylolisthesis. Few studies comparing fusion to nonoperative management reported differences in outcome by specific disease or general health subpopulations. Among those that did, we observed the effect of fusion compared to nonoperative management was slightly more favorable in patients with no additional comorbidities compared with those with additional comorbidities and more marked in nonsmokers compared with smokers. It is unclear from the literature which patients are the best candidates for fusion versus conservative management when experiencing CLBP without significant neurological impairment. Nonsmokers may be more likely to have a favorable surgical fusion outcome in CLBP patients. Comorbid disease presence has not been shown to definitively modify the effect of fusion. Further prospective studies that are designed to evaluate these and other subgroup effects are encouraged to confirm these findings. We recommend optimizing the management of medical co-morbidities and smoking cessation before considering surgical fusion in CLBP patients. Strength of recommendation: Weak.
    Spine 09/2011; 36(21 Suppl):S87-95. DOI:10.1097/BRS.0b013e31822ef89e · 2.45 Impact Factor
  • Spine 06/2011; 36(14):1167-8. DOI:10.1097/BRS.0b013e3182222c98 · 2.45 Impact Factor
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    ABSTRACT: Objective: High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.Clinical presentation: A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.Intervention: Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.Conclusion: Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.
    12/2010; 1(3):51-4. DOI:10.1055/s-0030-1267068
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    ABSTRACT: Although existing literature includes reports of isolated lower extremity monoparesis/monoplegia (MP) due to epidural or subdural haematomas, instances due to traumatic intraparenchymal contusions near the vertex have not been described [corrected].Due to the limitations of conventional axial computed tomographic (CT) imaging, the evidence of a vertex contusion may be under-appreciated if an overlying skull fracture is absent. Two cases of isolated MP due to vertex contusions are described and the physical forces involved in the head trauma are described to explain the location of the contusions. Vertex intraparenchymal contusions are rare because of the way the brain deforms in response to the accelerational forces acting on it during head trauma. This study analyses patients' injuries and addresses the importance of considering the forces acting on the brain when evaluating a victim of head trauma. Isolated lower extremity MP following head trauma is rare because haematomas in the fronto-parietal cortex near the midline that could produce such a deficit are rare. The limitations of typical axial CT imaging can be overcome with coronal reconstructions. Practitioners who evaluate patients with isolated MP after head injury should be aware of the possibility of an intraparenchymal lesion near the vertex as the cause of this deficit.
    Brain Injury 09/2010; 24(10):1231-5. DOI:10.3109/02699052.2010.495698 · 1.86 Impact Factor
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    James M Schuster, Dena Fischer, Joseph R Dettori
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    ABSTRACT: Study design: Systematic review Study rationale and context: There is controversy regarding the efficacy and safety of chemical prophylaxis to prevent deep venous thrombosis (DVT) and pulmonary embolism (PE) in elective spinal procedures.Commonly performed elective spine surgeries done through a posterior approach have a very low associated risk of DVT/PE. The lack of consensus is due in part to a limited amount of quality evidence based literature dealing with this issue. Objective: To compare chemical prophylaxis with no chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery. Methods: We undertook a systematic review of the literature to assess the efficacy and safety of chemical prophylaxis in preventing venous thromboembolism in elective thoracolumbar spine surgery. Pubmed, EMBASE, Cochrane, National Guideline Clearinghouse Databases as well as bibliographies of key articles were searched. Articles were reviewed by two independently working reviewers. Inclusion and exclusion criteria were set and each article was subject to a predefined quality rating scheme. Results: We identified only two articles meeting our inclusion criteria. Neither study demonstrated a significant difference between chemical prophylaxis versus no prophylaxis in preventing thromboembolic events. There was an increased incidence of perioperative bleeding with low dose Coumadin in one of the studies. Conclusion: The incidence of DVT and PE in commonly performed elective posterior spinal procedures is very low. While there is a limited amount of randomized literature looking at this issue, the current literature does not support the routine use of chemical prophylaxis for low risk patients undergoing these procedures.
    08/2010; 1(2):40-5. DOI:10.1055/s-0028-1100913
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    ABSTRACT: Meta-analytic costeffectiveness analysis. Our goal was to compare the results of different management strategies for trauma patients in whom the cervical spine was not clinically evaluable due to impaired consciousness, endotracheal intubation, or painful distracting injuries. We performed a structured literature review related to cervical spine trauma, radiographic clearance techniques (plain radiography, flexion/extension, CT, and MRI), and complications associated with semirigid collar use. Meta-analytic techniques were used to pool data from multiple sources to calculate pooled mean estimates of sensitivities and specificities of imaging techniques for cervical spinal clearance, rates of complications from various clearance strategies and from empirical use of semirigid collars. A decision analysis model was used to compare outcomes and costs among these strategies. Slightly more than 7.5% of patients who are clinically unevaluable have cervical spine injuries, and 42% of these injuries are associated with spinal instability. Sensitivity of plain radiography or fluoroscopy for spinal clearance was 57% (95% CI: 57%-60%). Sensitivities for CT and MRI alone were 83% (82%-84%) and 87% (84%-89%), respectively. Complications associated with collar use ranged from 1.3% (2 days) to 7.1% (10 days) but were usually minor and short-lived. Quadriplegia resulting from spinal instability missed by a clearance test had enormous impacts on longevity, quality of life, and costs. These impacts overshadowed the effects of prolonged collar application, even when the incidence of quadriplegia was extremely low. As currently used, neuroimaging studies for cervical spinal clearance in clinically unevaluable patients are not cost-effective compared with empirical immobilization in a semirigid collar.
    Spine 08/2010; 35(18):1721-8. DOI:10.1097/BRS.0b013e3181e9acb2 · 2.45 Impact Factor
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    ABSTRACT: Systematic review. The objectives of this systematic review were to determine the patient and perioperative risk factors that contribute to infections after spine surgery and to examine the level of evidence to support the use of therapeutic interventions to reduce infection rates. Infection continues to be one of the most common and feared complications after spine surgery. As such, it is used as a sentinel event for quality assurance processes. It is clear that the causes of infections after spine surgery are multifactorial and numerous patient- and procedure-related factors have been proposed as contributory elements. In addition, numerous perioperative adjuncts have been suggested to reduce infection rates. A systematic review of the English-language literature (published between January 1990 and June 2009) was undertaken to identify articles examining risk factors associated with and adjunct treatment measures for preventing surgical-site infections. Two independent reviewers assessed the level of evidence quality using the Grading of Recommendations Assessment, Development, and Evaluation criteria, and disagreements were resolved by consensus. Of the 127 articles identified, 32 met the criteria to undergo full-text review. Individual patient, operative, and perioperative variables have been identified that are associated with increased infection rates (i.e., older age, obesity, diabetes, malnutrition, higher American Society of Anesthesiologists score, posterior approaches, and blood transfusions) but these variables have not been combined to provide individual patient risks based on a composite of factors (e.g., risk stratification). Of the surgical adjuncts investigated, only irrigation with dilute betadine solution showed moderate support for reducing infection rates. It is clear that the causes of postoperative spinal site infections are multifactorial and related to a complex interplay of patient and procedural influences. Because of these complexities, for any individual and surgical procedure, predictable infection rates likely exist that do not extrapolate to 0. Although we have identified factors associated with increased infection rates, further studies will be required to allow multifactorial risk stratification for individual patients and to further investigate the use of therapeutic adjuncts.
    Spine 04/2010; 35(9 Suppl):S125-37. DOI:10.1097/BRS.0b013e3181d8342c · 2.45 Impact Factor
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    ABSTRACT: Increased intracranial pressure (ICP) can cause brain ischemia and compromised brain oxygen (PbtO2 < or = 20 mm Hg) after severe traumatic brain injury (TBI). We examined whether decompressive craniectomy (DC) to treat elevated ICP reduces the cumulative ischemic burden (CIB) of the brain and therapeutic intensity level (TIL). Ten severe TBI patients (mean age, 31.4 +/- 14.2 years) who had continuous PbtO2 monitoring before and after delayed DC were retrospectively identified. Patients were managed according to the guidelines for the management of severe TBI. The CIB was measured as the total time spent between a PbtO2 of 15 to 20, 10 to 15, and 0 to 10 mm Hg. The TIL was calculated every 12 hours. Mixed-effects models were used to estimate changes associated with DC. DC was performed on average 2.8 days after admission. DC was found to immediately reduce ICP (mean [SEM] decrease was 7.86 mm Hg [2.4 mm Hg]; P = .005). TIL, which was positively correlated with ICP (r = 0.46, P < or = .001), was reduced within 12 hours after surgery and continued to improve within the postsurgical monitoring period (P </= .001). The duration and severity of CIB were significantly reduced as an effect of DC in this group. The overall mortality rate in the group of 10 patients was lower than predicted at the time of admission (P = .015). These results suggest that a DC for increased ICP can reduce the CIB of the brain after severe TBI. We suggest that DC be considered early in a patient's clinical course, particularly when the TIL and ICP are increased.
    Neurosurgery 04/2010; 66(6):1111-8; discussion 1118-9. DOI:10.1227/01.NEU.0000369607.71913.3E · 3.03 Impact Factor
  • James M. Schuster
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    ABSTRACT: The management of a head injured patient with multiple other injuries presents one of the most challenging and difficult clinical scenarios in trauma critical care. This is, in part, due to the fact that the treatment of other injuries, such as orthopedic, spine, and craniofacial fractures, has the potential for worsening the neurologic outcome. This potential worsening is not necessarily directly related to the primary repair or the timing of surgery, but more to the fact that additional surgery with potential blood loss and possible resultant hypotension or hypoxia can adversely affect an injured brain. A single episode of hypotension or hypoxia can adversely affect the outcome of all severities of head injury [1–6].
    Damage Control Management in the Polytrauma Patient, 01/2010: pages 279-290; , ISBN: 978-0-387-89507-9
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    Injury Extra 01/2009; 40(1):1-3.

Publication Stats

130 Citations
47.64 Total Impact Points

Institutions

  • 2013–2014
    • Hospital of the University of Pennsylvania
      • Department of Orthopaedic Surgery
      Philadelphia, Pennsylvania, United States
  • 2008–2014
    • University of Pennsylvania
      • Department of Neurosurgery
      Philadelphia, Pennsylvania, United States
  • 2008–2013
    • William Penn University
      Filadelfia, Pennsylvania, United States