Roger Härtl

Weill Cornell Medical College, New York, New York, United States

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Publications (70)161.65 Total impact

  • Halinder S. Mangat, Roger Härtl
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    ABSTRACT: Hyperosmolar agents are commonly used as an initial treatment for the management of raised intracranial pressure (ICP) after severe traumatic brain injury (TBI). They have an excellent adverse-effect profile compared to other therapies, such as hyperventilation and barbiturates, which carry the risk of reducing cerebral perfusion. The hyperosmolar agent mannitol has been used for several decades to reduce raised ICP, and there is accumulating evidence from pilot studies suggesting beneficial effects of hypertonic saline (HTS) for similar purposes. An ideal therapeutic agent for ICP reduction should reduce ICP while maintaining cerebral perfusion (pressure). While mannitol can cause dehydration over time, HTS helps maintain normovolemia and cerebral perfusion, a finding that has led to a large amount of pilot data being published on the benefits of HTS, albeit in small cohorts. Prophylactic therapy is not recommended with mannitol, although it may be beneficial with HTS. To date, no large clinical trial has been performed to directly compare the two agents. The best current evidence suggests that mannitol is effective in reducing ICP in the management of traumatic intracranial hypertension and carries mortality benefit compared to barbiturates. Current evidence regarding the use of HTS in severe TBI is limited to smaller studies, which illustrate a benefit in ICP reduction and perhaps mortality. © 2015 New York Academy of Sciences.
    Annals of the New York Academy of Sciences 02/2015; · 4.38 Impact Factor
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    ABSTRACT: OBJECT Surgical decompression is the intervention of choice for lumbar spinal stenosis (LSS) when nonoperative treatment has failed. Standard open laminectomy is an effective procedure, but minimally invasive laminectomy through tubular retractors is an alternative. The aim of this retrospective case series was to evaluate the clinical and radiographic outcomes of this procedure in patients who underwent LSS and to compare outcomes in patients with and without preoperative spondylolisthesis. METHODS Patients with LSS without spondylolisthesis and with stable Grade I spondylolisthesis who had undergone minimally invasive tubular laminectomy between 2004 and 2011 were included in this analysis. Demographic, perioperative, and radiographic data were collected. Clinical outcome was evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS) scores, as well as Macnab's criteria. RESULTS Among 110 patients, preoperative spondylolisthesis at the level of spinal stenosis was present in 52.5%. At a mean follow-up of 28.8 months, scoring revealed a median improvement of 16% on the ODI, 2.75 on the VAS back, and 3 on the VAS leg, compared with the preoperative baseline (p < 0.0001). The reoperation rate requiring fusion at the same level was 3.5%. Patients with and without preoperative spondylolisthesis had no significant differences in their clinical outcome or reoperation rate. CONCLUSIONS Minimally invasive laminectomy is an effective procedure for the treatment of LSS. Reoperation rates for instability are lower than those reported after open laminectomy. Functional improvement is similar in patients with and without preoperative spondylolisthesis. This procedure can be an alternative to open laminectomy. Routine fusion may not be indicated in all patients with LSS and spondylolisthesis.
    Journal of neurosurgery. Spine. 01/2015;
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    ABSTRACT: A herniated intervertebral disc often causes back pain when disc tissue is displaced through a damaged annulus fibrosus. Currently the only methods available for annulus fibrosus repair involve mechanical closure of defect, which does little to address biological healing in the damaged tissue. Collagen hydrogels are injectable and have been used to repair annulus defects in vivo. In this study, high-density collagen hydrogels at 5, 10 and 15 mg/ml were used to repair defects made to intact rat caudal intervertebral discs in vitro. A group of gels at 15 mg/ml were also crosslinked with riboflavin at 0.03 mM, 0.07 mM or 0.10 mM. These crosslinked, high-density collagen gels maintained presence in the defect under loading and contributed positively to the mechanical response of damaged discs. Discs exhibited increases to 95% of undamaged effective equilibrium and instantaneous moduli as well as up to four fold decreases in effective hydraulic permeability from the damaged discs. These data suggest that high density collagen gels may be effective at restoring mechanical function of injured discs as well as potential vehicles for delivery of biological agents such as cells or growth factors that may aid in the repair of the annulus fibrosus. This article is protected by copyright. All rights reserved.
    Journal of Biomedical Materials Research Part A 12/2014; · 2.83 Impact Factor
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    ABSTRACT: OBJECT Increased intracranial pressure (ICP) in patients with traumatic brain injury (TBI) is associated with a higher mortality rate and poor outcome. Mannitol and hypertonic saline (HTS) have both been used to treat high ICP, but it is unclear which one is more effective. Here, the authors compare the effect of mannitol versus HTS on lowering the cumulative and daily ICP burdens after severe TBI. METHODS The Brain Trauma Foundation TBI-trac New York State database was used for this retrospective study. Patients with severe TBI and intracranial hypertension who received only 1 type of hyperosmotic agent, mannitol or HTS, were included. Patients in the 2 groups were individually matched for Glasgow Coma Scale score (GCS), pupillary reactivity, craniotomy, occurrence of hypotension on Day 1, and the day of ICP monitor insertion. Patients with missing or erroneous data were excluded. Cumulative and daily ICP burdens were used as primary outcome measures. The cumulative ICP burden was defined as the total number of days with an ICP of > 25 mm Hg, expressed as a percentage of the total number of days of ICP monitoring. The daily ICP burden was calculated as the mean daily duration of an ICP of > 25 mm Hg, expressed as the number of hours per day. The numbers of intensive care unit (ICU) days, numbers of days with ICP monitoring, and 2-week mortality rates were also compared between the groups. A 2-sample t-test or chi-square test was used to compare independent samples. The Wilcoxon signed-rank or Cochran-Mantel-Haenszel test was used for comparing matched samples. RESULTS A total of 35 patients who received only HTS and 477 who received only mannitol after severe TBI were identified. Eight patients in the HTS group were excluded because of erroneous or missing data, and 2 other patients did not have matches in the mannitol group. The remaining 25 patients were matched 1:1. Twenty-four patients received 3% HTS, and 1 received 23.4% HTS as bolus therapy. All 25 patients in the mannitol group received 20% mannitol. The mean cumulative ICP burden (15.52% [HTS] vs 36.5% [mannitol]; p = 0.003) and the mean (± SD) daily ICP burden (0.3 ± 0.6 hours/day [HTS] vs 1.3 ± 1.3 hours/day [mannitol]; p = 0.001) were significantly lower in the HTS group. The mean (± SD) number of ICU days was significantly lower in the HTS group than in the mannitol group (8.5 ± 2.1 vs 9.8 ± 0.6, respectively; p = 0.004), whereas there was no difference in the numbers of days of ICP monitoring (p = 0.09). There were no significant differences between the cumulative median doses of HTS and mannitol (p = 0.19). The 2-week mortality rate was lower in the HTS group, but the difference was not statistically significant (p = 0.56). CONCLUSIONS HTS given as bolus therapy was more effective than mannitol in lowering the cumulative and daily ICP burdens after severe TBI. Patients in the HTS group had significantly lower number of ICU days. The 2-week mortality rates were not statistically different between the 2 groups.
    Journal of Neurosurgery 11/2014; · 3.23 Impact Factor
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    ABSTRACT: OBJECT The gold-standard surgical approach to the odontoid is via the transoral route. This approach necessitates opening of the oropharynx and is associated with risks of infection, and swallowing and breathing complications. The endoscopic endonasal approach has the potential to reduce these complications as the oral cavity is avoided. There are fewer than 25 such cases reported to date. The authors present a consecutive, single-institution series of 9 patients who underwent the endonasal endoscopic approach to the odontoid. METHODS The charts of 9 patients who underwent endonasal endoscopic surgery to the odontoid between January 2005 and August 2013 were reviewed. The clinical presentation, radiographic findings, surgical management, complications, and outcome, particularly with respect to time to extubation and feeding, were analyzed. Radiographic measurements of the distance between the back of the odontoid and the front of the cervicomedullary junction (CMJ) were calculated, as well as the location of any residual bone fragments. RESULTS There were 7 adult and 2 pediatric patients in this series. The mean age of the adults was 54.8 years; the pediatric patients were 7 and 14 years. There were 5 females and 4 males. The mean follow-up was 42.9 months. Symptoms were resolved or improved in all but 1 patient, who had concurrent polyneuropathy. The distance between the odontoid and CMJ increased by 2.34 ± 0.43 mm (p = 0.03). A small, clinically insignificant fragment remained after surgery, always on the left side, in 57% of patients. Mean times to extubation and oral feeding were on postoperative Days 0.3 and 1, respectively. There was one posterior cervical wound infection; there were 2 cases of epistaxis requiring repacking of the nose and no instances of breathing or swallowing complications or velopharyngeal insufficiency. CONCLUSIONS This series of 9 cases of endonasal endoscopic odontoidectomy highlights the advantages of the approach in permitting early extubation and early feeding and minimizing complications compared with transoral surgery. Special attention must be given to bone on the left side of the odontoid if the surgeon is standing on the right side.
    Journal of neurosurgery. 10/2014;
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    ABSTRACT: Object Anterior cervical plating decreases the risk of pseudarthrosis following anterior cervical discectomy and fusion (ACDF). Dysphagia is a common complication of ACDF, with the anterior plate implicated as a potential contributor. A zero-profile, stand-alone polyetheretherketone (PEEK) interbody spacer has been postulated to minimize soft-tissue irritation and postoperative dysphagia, but studies are limited. The object of the present study was to determine the clinical and radiological outcomes for patients who underwent ACDF using a zero-profile integrated plate and spacer device, with a focus on the course of postoperative prevertebral soft-tissue thickness and the incidence of dysphagia. Methods Using a surgical database, the authors conducted a retrospective analysis of all patients who had undergone ACDF between August 2008 and October 2011. All patients received a Zero-P implant (DePuy Synthes Spine). The Neck Disability Index (NDI) and visual analog scale (VAS) scores for arm and neck pain were documented. Dysphagia was determined using the Bazaz criteria. Prevertebral soft-tissue thickness, spinal alignment, and subsidence were assessed as well. Results Twenty-two male and 19 female consecutive patients, with a mean age of 58.4 ± 14.68, underwent ACDF (66 total operated levels) in the defined study period. The mean clinical follow-up in 36 patients was 18.6 ± 9.93 months. Radiological outcome in 37 patients was assessed at a mean follow-up of 9.76 months (range 7.2-19.7 months). There were significant improvements in neck and arm VAS scores and the NDI following surgery. The neck VAS score improved from a median of 6 (range 0-10) to 0 (range 0-8; p < 0.001). The arm VAS score improved from a median of 2 (range 0-10) to 0 (range 0-7; p = 0.006). Immediate postoperative dysphagia was experienced by 58.4% of all patients. Complete resolution was demonstrated in 87.8% of affected patients at the latest follow-up. The overall median Bazaz score decreased from 1 (range 0-3) immediately postoperatively to 0 (range 0-2; p < 0.001) at the latest follow-up. Prevertebral soft-tissue thickness significantly decreased across all levels from a mean of 15.8 ± 4.38 mm to 10.1 ± 2.93 mm. Postoperative lordosis was maintained at the latest follow-up. Mean subsidence from the immediate postoperative to the latest follow-up was 4.1 ± 4.7 mm (p < 0.001). Radiographic fusion was achieved in 92.6% of implants. No correlation was found between prevertebral soft-tissue thickness and Bazaz dysphagia score. Conclusions A zero-profile integrated plate and spacer device for ACDF surgery produces clinical and radiological outcomes that are comparable to those for nonintegrated plate and spacer constructs. Chronic dysphagia rates are comparable to or better than those for previously published case series.
    Journal of Neurosurgery Spine 08/2014; · 2.36 Impact Factor
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    ABSTRACT: Object Extreme lateral interbody fusion (ELIF) is a popular technique for anterior fixation of the thoracolumbar spine. Clinical and radiological outcome studies are required to assess safety and efficacy. The aim of this study was to describe the functional and radiological impact of ELIF in a degenerative disc disease population with a longer follow-up and to assess the durability of this procedure. Methods Demographic and perioperative data for all patients who had undergone ELIF for degenerative lumbar disorders between 2007 and 2011 were collected. Trauma and tumor cases were excluded. For radiological outcome, the preoperative, immediate postoperative, and latest follow-up coronal Cobb angle, lumbar sagittal lordosis, bilateral foraminal heights, and disc heights were measured. Pelvic incidence (PI) and PI-lumbar lordosis (PI-LL) mismatch were assessed in scoliotic patients. Clinical outcome was evaluated using the Oswestry Disability Index (ODI) and visual analog scale (VAS), as well as the Macnab criteria. Results One hundred forty-five vertebral levels were surgically treated in 90 patients. Pedicle screw and rod constructs and lateral plates were used to stabilize fixation in 77% and 13% of cases, respectively. Ten percent of cases involved stand-alone cages. At an average radiological follow-up of 12.6 months, the coronal Cobb angle was 10.6° compared with 23.8° preoperatively (p < 0.0001). Lumbar sagittal lordosis increased by 5.3° postoperatively (p < 0.0001) and by 2.9° at the latest follow-up (p = 0.014). Foraminal height and disc height increased by 4 mm (p < 0.0001) and 3.3 mm (p < 0.0001), respectively, immediately after surgery and remained significantly improved at the last follow-up. Separate evaluation of scoliotic patients showed no statistically significant improvement in PI and PI-LL mismatch either immediately postoperatively or at the latest follow-up. Clinical evaluation at an average follow-up of 17.6 months revealed an improvement in the ODI and the VAS scores for back, buttock, and leg pain by 21.1% and 3.7, 3.6, and 3.7 points, respectively (p < 0.0001). According to the Macnab criteria, 84.8% of patients had an excellent, good, or fair functional outcome. New postoperative thigh numbness and weakness was detected in 4.4% and 2.2% of the patients, respectively, which resolved within the first 3 months after surgery in all but 1 case. Conclusions This study provides what is to the authors' knowledge the most comprehensive set of radiological and clinical outcomes of ELIF in a fairly large population at a midterm follow-up. Extreme lateral interbody fusion showed good clinical outcomes with a low complication rate. The procedure allows for at least midterm clinically effective restoration of disc and foraminal heights. Improvement in coronal deformity and a small but significant increase in sagittal lordosis were observed. Nonetheless, no significant improvement in the PI-LL mismatch was achieved in scoliotic patients.
    Journal of neurosurgery. Spine 04/2014; · 1.61 Impact Factor
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    ABSTRACT: Radiculopathy caused by foraminal nerve root compression is a common pathology in the lumbar spine. Surgical decompression via a conventional open foraminotomy is the treatment of choice when surgery is indicated. Minimally invasive tubular foraminotomy through a contralateral approach is a potentially effective surgical alternative. The aim of this retrospective cohort study was to evaluate the efficacy and benefits of this approach for treatment of radiculopathy. Patients with unilaterally dominant lower extremity radiculopathy, who underwent minimally invasive lumbar foraminotomy through tubular retractors via a contralateral approach between 2010 and 2012, were included. Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for back and leg pain were evaluated pre-operatively, post-operatively, and at the latest follow-up. Functional outcome was evaluated using MacNab's criteria. For the total 32 patients, post-operatively there was significant improvement in the ODI (p=0.006), VAS back pain (p<0.0001), and VAS leg pain on the pathology and the approach side (p = 0.004, p=0.021, respectively). At follow-up of 12.3 ± 1.7 months, there was also significant improvement in the ODI (p<0.0001), VAS back pain (p=0.001), and VAS leg pain on the pathology and the approach side (p<0.0001, p = 0.001, respectively). The functional outcome was excellent and good in 95.2%. One patient required fusion (3.1%). A minimally invasive, facet-sparing contralateral approach is an effective technique for treatment of radiculopathy due to foraminal compression. It also allows for decompression of lumbar spinal stenosis and bilateral lateral recess decompression without the need for fusion.
    Neurosurgery 03/2014; · 3.03 Impact Factor
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    ABSTRACT: Object Tissue-engineered intervertebral discs (TE-IVDs) represent a new experimental approach for the treatment of degenerative disc disease. Compared with mechanical implants, TE-IVDs may better mimic the properties of native discs. The authors conducted a study to evaluate the outcome of TE-IVDs implanted into the rat-tail spine using radiological parameters and histology. Methods Tissue-engineered intervertebral discs consist of a distinct nucleus pulposus (NP) and anulus fibrosus (AF) that are engineered in vitro from sheep IVD chondrocytes. In 10 athymic rats a discectomy in the caudal spine was performed. The discs were replaced with TE-IVDs. Animals were kept alive for 8 months and were killed for histological evaluation. At 1, 5, and 8 months, MR images were obtained; T1-weighted sequences were used for disc height measurements, and T2-weighted sequences were used for morphological analysis. Quantitative T2 relaxation time analysis was used to assess the water content and T1ρ-relaxation time to assess the proteoglycan content of TE-IVDs. Results Disc height of the transplanted segments remained constant between 68% and 74% of healthy discs. Examination of TE-IVDs on MR images revealed morphology similar to that of native discs. T2-relaxation time did not differ between implanted and healthy discs, indicating similar water content of the NP tissue. The size of the NP decreased in TE-IVDs. Proteoglycan content in the NP was lower than it was in control discs. Ossification of the implanted segment was not observed. Histological examination revealed an AF consisting of an organized parallel-aligned fiber structure. The NP matrix appeared amorphous and contained cells that resembled chondrocytes. Conclusions The TE-IVDs remained viable over 8 months in vivo and maintained a structure similar to that of native discs. Tissue-engineered intervertebral discs should be explored further as an option for the potential treatment of degenerative disc disease.
    Journal of neurosurgery. Spine 02/2014; · 1.61 Impact Factor
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    ABSTRACT: Study Design. Animal experimental studyObjective. To evaluate a novel quantitative imaging technique for assessing disc degeneration.Summary of Background Data. T2-relaxation time (T2-RT) measurements have been used to quantitatively assess disc degeneration. T2 values correlate with the water content of inter vertebral disc tissue and thereby allow for the indirect measurement of nucleus pulposus (NP) hydration.Methods. We developed an algorithm to subtract out MRI voxels not representing NP tissue based on T2-RT values. Filtered NP voxels were used to measure nuclear size by their amount and nuclear hydration by their mean T2-RT. This technique was applied to 24 rat-tail intervertebral discs' (IVDs), which had been punctured with an 18-gauge needle according to different techniques to induce varying degrees of degeneration. NP voxel count and average T2-RT were used as parameters to assess the degeneration process at 1 and 3 months post puncture.NP voxel counts were evaluated against X-ray disc height measurements and qualitative MRI studies based on the Pfirrmann grading system.Tails were collected for histology to correlate NP voxel counts to histological disc degeneration grades and to NP cross-sectional area measurements.Results. NP voxel count measurements showed strong correlations to qualitative MRI analyses (R = 0.79, p<0.0001), histological degeneration grades (R = 0.902, p<0.0001) and histological NP cross-sectional area measurements (R = 0.887, p<0.0001).In contrast to NP voxel counts, the mean T2-RT for each punctured group remained constant between months 1 and 3. The mean T2-RTs for the punctured groups did not show a statistically significant difference from those of healthy IVDs (63.55ms ±5.88ms month 1 and 62.61ms ±5.02ms) at either time point.Conclusion. The NP voxel count proved to be a valid parameter to quantitatively assess disc degeneration in a needle puncture model. The mean NP T2-RT does not change significantly in needle-puncture induced degenerated IVDs. IVDs can be segmented into different tissue components according to their innate T2-RT.
    Spine 12/2013; · 2.45 Impact Factor
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    ABSTRACT: Study Design. Animal in vivo study.Objective. To test the capability of high-density collagen gel to repair annular defects.Summary of Background Data. Annular defects are associated with spontaneous disc herniations and disc degeneration, which can lead to significant morbidity. Persistent annular defects following surgical discectomies can increase reherniation rates. Several synthetic and biological materials have been developed for annular repair. This is the first study to test an injectable biomaterial in vivo.Methods. We punctured caudal intervertebral discs in 42 athymic rats, using an 18-gauge needle to create an annular defect. High-density collagen (HDC), either alone or cross-linked with riboflavin (RF), was injected into the defect. There were four separate study groups: HDC, HDC cross-linked with either 0.25mM RF or 0.50mM RF, and a negative control that was punctured and not treated. The animals were followed for five weeks; X-rays were used to assess disc heights and MR imaging to evaluate degenerative changes. We developed an algorithm based on T2-relaxation time measurements to assess the size of the nucleus pulposus (NP). Tails were collected for histological analysis to evaluate disc degeneration and measure the cross-sectional area of the NP.Results. After five weeks, the control and the uncross-linked HDC groups both showed signs of progressive degenerative changes with minimal or no residual NP tissue in the disc space. Cross-linking significantly improved the ability of HDC gels to repair annular defects. The 0.50mM RF cross-linked group showed only a slight decrease in nuclear tissue when compared to healthy discs, with no signs of IVD degeneration. The AF was partially repaired by a fibrous cap that bridged the defect. Host fibroblasts infiltrated and remodeled the injected collagen.Conclusion. HDC is capable of repairing annular defects induced by needle puncture. The stiffness of HDC can be modified by riboflavin cross-linking and appears to positively affect the repair mechanism. These results need to be replicated in a larger animal model.
    Spine 11/2013; · 2.45 Impact Factor
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    ABSTRACT: Object In spite of evidence that use of the Brain Trauma Foundation Guidelines for the Management of Severe Traumatic Brain Injury (Guidelines) would dramatically reduce morbidity and mortality, adherence to these Guidelines remains variable across trauma centers. The authors analyzed 2-week mortality due to severe traumatic brain injury (TBI) from 2001 through 2009 in New York State and examined the trends in adherence to the Guidelines. Methods The authors calculated trends in adherence to the Guidelines and age-adjusted 2-week mortality rates between January 1, 2001, and December 31, 2009. Univariate and multivariate logistic regression analyses were performed to evaluate the effect of time period on case-fatality. Intracranial pressure (ICP) monitor insertion was modeled in a 2-level hierarchical model using generalized linear mixed effects to allow for clustering by different centers. Results From 2001 to 2009, the case-fatality rate decreased from 22% to 13% (p < 0.0001), a change that remained significant after adjusting for factors that independently predict mortality (adjusted OR 0.52, 95% CI 0.39-0.70; p < 0.0001). Guidelines adherence increased, with the percentage of patients with ICP monitoring increasing from 56% to 75% (p < 0.0001). Adherence to cerebral perfusion pressure treatment thresholds increased from 15% to 48% (p < 0.0001). The proportion of patients having an ICP elevation greater than 25 mm Hg dropped from 42% to 29% (p = 0.0001). Conclusions There was a significant reduction in TBI mortality between 2001 and 2009 in New York State. Increase in Guidelines adherence occurred at the same time as the pronounced decrease in 2-week mortality and decreased rate of intracranial hypertension, suggesting a causal relationship between Guidelines adherence and improved outcomes. Our findings warrant future investigation to identify methods for increasing and sustaining adherence to evidence-based Guidelines recommendations.
    Journal of Neurosurgery 10/2013; · 3.15 Impact Factor
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    ABSTRACT: Object The paracoccygeal approach allows for instrumentation of L5/S1 and L4/5 by using a transsacral rod (AxiaLIF; TransS1, Inc.). The authors analyzed clinical and radiographic outcomes of 1- or 2-level AxiaLIF procedures with focus on durability of the construct. Methods This was a retrospective study of 38 consecutive patients who underwent either 1-level (32 patients) or 2-level (6 patients) AxiaLIF procedures at the authors' institution. The Oswestry Disability Index (minimum clinically important difference [MCID] ≥ 12) and visual analog scale ([VAS]; MCID ≥ 3) scores were collected. Disc height and Cobb angles were measured on pre- and postoperative radiographs. Bony fusion was determined on CT scans or flexion/extension radiographs. Results Implantation of a transsacral rod allowed for intraoperative distraction of the L5/S1 intervertebral space and resulted in increased segmental lordosis postoperatively. At a mean follow-up time of 26.2 ± 2.4 months, however, graft subsidence (1.9 mm) abolished partial correction of segmental lordosis. Moreover, subsidence of the construct reduced L5/S1 lordosis in patients with 1-level AxiaLIF by 3.2° and L4-S1 lordosis in patients with 2-level procedures by 10.1° compared with preoperative values (p < 0.01). Loss of segmental lordosis predicted failure to improve VAS scores for back pain in the patient cohort (p < 0.05). Overall, surgical intervention led to modest symptomatic improvement; only 26.3% of patients achieved an MCID of the Oswestry Disability Index and 50% of patients an MCID of the VAS score for back pain. At last follow-up, 71.9% of L5/S1 levels demonstrated bony fusion (1-level AxiaLIF 80.8%, 2-level AxiaLIF 33.3%; p < 0.05), whereas none of the L4/5 levels in 2-level AxiaLIF fused. Five constructs developed pseudarthrosis and required surgical revision. Conclusions The AxiaLIF procedure constitutes a minimally invasive technique for L5/S1 instrumentation, with low perioperative morbidity. However, the axial rod provides inadequate long-term anterior column support, which leads to subsidence and loss of segmental lordosis. Modification of the transsacral technique to allow for placement of a solid interposition graft may counteract subsidence of the construct.
    Journal of neurosurgery. Spine 08/2013; · 1.61 Impact Factor
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    ABSTRACT: In a resource-poor environment such as rural East Africa expensive medical devices such as Ctscanners are rare. The CT-scanner of rural Haydom Lutheran Hospital (HLH) in Tanzania offers therefore a unique chance to observe possible differences with urban medical centers in the disease pattern of trauma-related cranial pathologies. To compare traumatic brain injuries (TBI) between a rural and an urban area of Tanzania. Retrospective Study METHODS: HLH has 350 beds and one computed tomography. The urban Aga Khan Hospital (AKH) is a private hospital with 80 beds and one CT-scanner. Data of 248 patients at HLH and of 432 patients at AKH, who carried a diagnosis of TBI could be collected. The prevalence of TBI was significantly higher in the rural area compared to the urban area (34.2% vs. 21.9%, p<0.0001). TBI due to violence was noted to occur more frequently at HLH, road traffic accidents were more frequent at AKH. The number of patients showing a normal CT-result was significantly higher in the urban area (53.0% vs. 35.9%, p<0.0001). Bone fractures (35.9% vs. 15.7%, p<0.0001) and pneumocephalus (6.9% vs. 0.9%, p<0.0001) were diagnosed significantly more frequently in the rural survey. Soft tissue swelling (11.6% vs. 1.2%, p < 0.0001) and frontal sinus injuries (7.4%vs. 0.4%, p<0.0001) were observed significantly more often in the urban setting. This study documents the burden of TBI and the differences in TBI-related CT diagnoses and their incidence between urban and rural areas in Eastern Africa. These results are important as they demonstrate that patients with severe TBI are not a primarily urban concern. Management of TBI should be included in training curricula for health personnel alike irrespective of whether their work place is primarily urban or rural.
    World Neurosurgery 08/2013; · 2.42 Impact Factor
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    ABSTRACT: Advanced intervertebral disc (IVD) degeneration, a major cause of back pain in the United States, is treated using invasive surgical intervention which may cause further degeneration is the future. Because of the limitations of traditional solutions, tissue engineering therapies have become increasingly popular. IVDs have two distinct regions, the inner nucleus pulposus (NP) which is jelly-like and rich in glycosaminoglycans (GAGs) and the outer annulus fibrosus (AF) which is organized into highly collagenous lamellae. Tissue engineered scaffolds, as well as whole organ culture systems have been developed. These culture systems may help elucidate the initial causes of disc degeneration. To create an effective tissue engineered therapy, researchers have focused on designing materials that mimic the properties of these two regions to be used independently or in concert. The few in vivo studies show promise in retaining disc height and MRI T2 signal intensity, the gold standard in determining disc health.
    Current Opinion in Biotechnology 06/2013; · 8.04 Impact Factor
  • Journal of neurosurgery. Spine 05/2013; 18(5):530-3. · 1.61 Impact Factor
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    ABSTRACT: Context: Recently, concussion has become a topic of much discussion within sports. The goal of this review is to provide an overview of the literature concerning the definition of concussion, management of initial injury, return to play, and future health risks.
    Sports Health A Multidisciplinary Approach 03/2013; 5(2):160-164.
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    ABSTRACT: Object Three-dimensional spinal navigation increases screw accuracy, but its implementation in clinical practice has been difficult, mainly because of surgeons' concerns about increased operative times, disturbance of workflow, and safety. The authors present a custom-designed navigated guide that addresses some of these concerns by allowing for drilling, tapping, and placing the final screw via a minimally invasive approach without the need for K-wires. In this paper, the authors' goal was to describe the technical aspects of the navigated guide tube as well as pedicle screw accuracy. Methods The authors present the technical details of a navigated guide that allows drilling, tapping, and the placement of the final screw without the need for K-wires. The first 10 patients who received minimally invasive mini-open spinal pedicle screws are presented. The case series focuses on the immediate postoperative outcomes, pedicle screw accuracy, and pedicle screw-related complications. An independent board-certified neuroradiologist determined pedicle screw accuracy according to a 4-tiered grading system. Results The navigated guide allowed successful placement of mini-open pedicle screws as part of posterior fixation from L-1 to S-1 without the use of K-wires. Only 7-mm-diameter screws were placed, and 72% of screws were completely contained within the pedicle. Breaches less than 2 mm were seen in 23% of cases, and these were all lateral except for one screw. Breaches were related to the lateral to medial trajectory chosen to avoid the superior facet joint. There were no complications related to pedicle screw insertion. Conclusions A novel customized navigated guide tube is presented that facilitates the workflow and allows accurate placement of mini-open pedicle screws without the need for K-wires.
    Journal of neurosurgery. Spine 11/2012; · 1.61 Impact Factor
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    ABSTRACT: BACKROUND: The paucity of neurosurgical care in East Africa remains largely unaddressed. A sustained investment in local health infrastructures and staff training is needed to create an independent surgical capacity. The Madaktari organization has addressed this issue by starting initiatives to train local general surgeons and assistant medical officers in basic neurosurgical procedures. We report illustrative cases since beginning of the program in Mwanza in 2009 and focus on the most recent training period. METHODS: A multi-institutional neurosurgical training program and a surgical database was created at a tertiary referral center in Mwanza, Tanzania. We collected clinical data on consecutive patients that underwent a neurosurgical procedure between September 9(th) and December 1(st), 2011. All procedures were performed by a local surgeon under the supervision of a visiting neurosurgeon. Since the inception of the training initiative, comprehensive multidisciplinary training courses in Tanzania and an annual visiting fellowship for East African surgeons to travel to a major US medical center have been established. RESULTS: At initial visits infrastructure and feasibility of complex case scenarios was assessed. Surgeries for brain tumors and complex spinal cases were performed. During the 3-month training period, 62 patients underwent surgery. Pediatric hydrocephalus comprised 52 % of patients, 11% suffered from meningomyelocelia, and 6% presented with an encephalocele. 24% of patients were treated for trauma-related conditions representing 75% of the adult patients. 10% of patients had surgery because of traumatic spine injury, and 15% of operations were on severe head injury patients. 6% of patients presented with degenerative spine disease. One patient sustained a fatal peri-operative complication. At the end of the training period, the local general surgeon was able to perform all basic neurosurgical cases independently. CONCLUSION: Neurosurgical care in Tanzania needs to address a diverse, unique disease burden. We found that local surgeons could be enabled to safely perform basic cranial and spinal neurosurgical proceduresthrough immersive, one-on-one on-site collaborations, multidisciplinary courses, and educational visiting fellowships.
    World Neurosurgery 09/2012; · 2.42 Impact Factor
  • Christoph P. Hofstetter, Roger Härtl
    World Neurosurgery 09/2012; · 2.42 Impact Factor

Publication Stats

661 Citations
161.65 Total Impact Points


  • 2006–2014
    • Weill Cornell Medical College
      • • Department of Neurological Surgery
      • • Weill Cornell Breast Center
      New York, New York, United States
  • 2011–2012
    • University Center Rochester
      • Department of Neurosurgery
      Rochester, Minnesota, United States
    • Muhimbili Orthopaedic Institute (MOI)
      Dār es Salām, Dar es Salaam, Tanzania
    • Cornell University
      • Department of Biomedical Engineering
      Ithaca, NY, United States
  • 2007–2012
    • New York Presbyterian Hospital
      • Department of Neurological Surgery
      New York City, New York, United States
  • 2010
    • Technische Universität München
      München, Bavaria, Germany
    • Ludwig-Maximilian-University of Munich
      • Interdisciplinary Centre for Palliative Medicine
      München, Bavaria, Germany
  • 2006–2010
    • Barrow Neurological Institute
      • Department of Neurosurgery
      Phoenix, AZ, United States
  • 2009
    • Karolinska Institutet
      • Institutionen för klinisk neurovetenskap
      Solna, Stockholm, Sweden