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Article ; Online: Analysis of spinal canal diameter in the placement of thoracic spinal cord stimulator paddle leads.

Ragel, Brian T / Riedman, Tressa / McGehee, Matthew / Raslan, Ahmed M

Pain practice : the official journal of World Institute of Pain

2023 Volume 24, Issue 1, Page(s) 91–100

Abstract: Background: Neurologic deficit is known as a rare complication of thoracic spinal cord stimulator (SCS) paddle lead implantation, but many believe its incidence after SCS paddle lead placement is under-reported. It is possible that imaging ... ...

Abstract	Background: Neurologic deficit is known as a rare complication of thoracic spinal cord stimulator (SCS) paddle lead implantation, but many believe its incidence after SCS paddle lead placement is under-reported. It is possible that imaging characteristics may be used to help predict safe paddle lead placement. Objective: This imaging study was undertaken to determine the minimum canal diameter required for safe paddle lead placement. Methods: Patients who underwent thoracic laminotomy for new SCS paddle lead placement from January 2018 to March 2023 were identified retrospectively. Preoperative thoracic canal diameter was measured in the sagittal plane perpendicular to the disc space from T5/6 to T11/12. These thoracic levels were chosen because they span the most common levels targeted for SCS placement. Patients with and without new neurologic deficits were compared using a Mann-Whitney U-test. Results: Of 185 patients initially identified, 180 had thoracic imaging available for review. One (0.5%) and 2 (1.1%) of 185 patients complained of permanent and transient neurologic deficit after thoracic SCS placement, respectively. Patients with neurologic deficits had average canal diameters of <11 mm. The average canal diameter of patients with and without neurologic deficits was 10.2 mm (range 6.1-12.9 mm) and 13.0 mm (range 5.9-20.2), respectively (p < 0.0001). Conclusion: Postoperative neurologic deficit is an uncommon complication after thoracic laminotomy for SCS paddle lead placement. The authors recommend ensuring a starting thoracic canal diameter of at least 12 mm to accommodate a SCS paddle lead measuring 2 mm thick to ensure a final diameter of >10 mm. If canal diameter is <12 mm, aggressive undercutting of the lamina, a second laminotomy, or placement of smaller SCS wire leads should be considered.
MeSH term(s)	Humans ; Retrospective Studies ; Electrodes, Implanted/adverse effects ; Spinal Cord ; Electric Stimulation Therapy/methods ; Spinal Canal/diagnostic imaging ; Spinal Canal/surgery ; Spinal Cord Stimulation/adverse effects ; Spinal Cord Stimulation/methods
Language	English
Publishing date	2023-08-25
Publishing country	United States
Document type	Journal Article
ZDB-ID	2151272-3
ISSN	1533-2500 ; 1530-7085
ISSN (online)	1533-2500
ISSN	1530-7085
DOI	10.1111/papr.13289
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Article: Timing of cranioplasty after decompressive craniectomy for trauma.

Piedra, Mark P / Nemecek, Andrew N / Ragel, Brian T

Surgical neurology international

2014 Volume 5, Page(s) 25

Abstract: Background: The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications.: Methods: Consecutive ...

Abstract	Background: The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications. Methods: Consecutive cases of patients who underwent autologous cranioplasty after decompressive craniectomy for trauma at a single Level I Trauma Center were studied in a retrospective 10 year data review. Associations of categorical variables were compared using Chi-square test or Fisher's exact test. Results: A total of 157 patients were divided into early (<12 weeks; 78 patients) and late (≥12 weeks; 79 patients) cranioplasty cohorts. Baseline characteristics were similar between the two cohorts. Cranioplasty operative time was significantly shorter in the early (102 minutes) than the late (125 minutes) cranioplasty cohort (P = 0.0482). Overall complication rate in both cohorts was 35%. Infection rates were lower in the early (7.7%) than the late (14%) cranioplasty cohort as was bone graft resorption (15% early, 19% late), hydrocephalus rate (7.7% early, 1.3% late), and postoperative hematoma incidence (3.9% early, 1.3% late). However, these differences were not statistically significant. Patients <18 years of age were at higher risk of bone graft resorption than patients ≥18 years of age (OR 3.32, 95% CI 1.25-8.81; P = 0.0162). Conclusions: After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs.
Language	English
Publishing date	2014-02-25
Publishing country	United States
Document type	Journal Article
ISSN	2229-5097
ISSN	2229-5097
DOI	10.4103/2152-7806.127762
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Article ; Online: Aberrant signaling pathways in meningiomas.

Ragel, Brian T / Jensen, Randy L

Journal of neuro-oncology

2010 Volume 99, Issue 3, Page(s) 315–324

Abstract: In this article, we provide a brief description of the current understanding of aberrant signaling pathways in meningiomas. Cell signaling pathways are responsible for cellular differentiation, development, growth, growth inhibition, and death. In fact, ... ...

Abstract	In this article, we provide a brief description of the current understanding of aberrant signaling pathways in meningiomas. Cell signaling pathways are responsible for cellular differentiation, development, growth, growth inhibition, and death. In fact, signaling pathways can affect multiple intracellular functions, including those responsible for development, angiogenesis, and apoptosis. Ultimately, a further understanding of the signaling pathways involved in meningioma tumorigenesis will lead to the development and application of novel molecular treatments, such as small molecule inhibitors or interfering ribonucleic acid technologies.
MeSH term(s)	Animals ; Humans ; Meningeal Neoplasms/metabolism ; Meningeal Neoplasms/pathology ; Meningioma/metabolism ; Meningioma/pathology ; Signal Transduction
Language	English
Publishing date	2010-09-14
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	604875-4
ISSN	1573-7373 ; 0167-594X
ISSN (online)	1573-7373
ISSN	0167-594X
DOI	10.1007/s11060-010-0381-8
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Article ; Online: Introduction: military neurosurgery, past and present.

Klimo, Paul / Ragel, Brian T

Neurosurgical focus

2010 Volume 28, Issue 5, Page(s) Introduction

Abstract: ... techniques by Ragel and colleagues and cranioplasty outcomes by Stephens and colleagues. After reading ...

Abstract	For a physician has the worth of many other warriors, both for the excision of arrows and for the administration of soothing drugs. Homer, Iliad XI.514-515 Ever since armed conflict has been used as a means to settle disputes among men, there have been those who have been tasked to mend the wounds that ravage a soldier's body from the weapons of war. The Iliad portrays the pivotal 10th year of the legendary Trojan War, during which a schism in the Greek leadership prolongs the extended siege of the city of Troy. In the midst of this martial epic come the lines quoted above, quietly attesting to the value of the military physician, even under the crude conditions of the Greek Dark Age. They are uttered by Idomeneus, one of the foremost Greeks, when he is enjoining one of his comrades, Nestor, to rescue the injured Greek physician Machaon and take him back from the line to treat his wounds. He is afraid that Machaon will be captured by the Trojans, a loss far greater than that of any other single warrior. Duty to country has helped shape the careers of many neurosurgeons, including iconic US figures such as Harvey Cushing and Donald Matson. This issue of Neurosurgical Focus celebrates the rich history of military neurosurgery from the wars of yesterday to the conflicts of today. We have been humbled by the tremendous response to this topic. The 25 articles within this issue will provide the reader with both a broad and an in-depth look at the many facets of military neurosurgery. We have attempted to group articles based on their predominant topic. We also encourage our audience to read other recently published articles. The first 8 articles relate to the current conflicts in Afghanistan and Iraq. The lead article, written by Randy Bell and colleagues from the National Naval Medical Center and Walter Reed Army Medical Center, discusses what is arguably one of the most important contributions by military neurosurgeons from these 2 conflicts: the rapid and aggressive use of decompressive craniectomies. This is followed by articles on decompressive craniectomy techniques by Ragel and colleagues and cranioplasty outcomes by Stephens and colleagues. After reading these articles, the reader will come away with an appreciation of the often complex nature of wartime penetrating and closed-head injuries and the remarkable recovery that many injured soldiers make with time.
MeSH term(s)	Afghanistan ; History, 21st Century ; Humans ; Iraq ; Male ; Military Medicine/history ; Military Medicine/methods ; Neurosurgery/history ; Neurosurgery/methods ; Neurosurgical Procedures/methods ; United States ; Warfare
Language	English
Publishing date	2010-05
Publishing country	United States
Document type	Historical Article ; Introductory Journal Article
ZDB-ID	2026589-X
ISSN	1092-0684 ; 1092-0684
ISSN (online)	1092-0684
ISSN	1092-0684
DOI	10.3171/2010.3.FOCUSMar2010Intro
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Article ; Online: Metastatic renal cell carcinoma to the third ventricle resembling a colloid cyst.

Wagner, Kate M / Thompson, Eric M / Ragel, Brian T

Acta neurochirurgica

2013 Volume 155, Issue 4, Page(s) 737–739

MeSH term(s)	Brain Neoplasms/diagnosis ; Brain Neoplasms/pathology ; Brain Neoplasms/secondary ; Brain Neoplasms/surgery ; Carcinoma, Renal Cell/pathology ; Carcinoma, Renal Cell/surgery ; Colloid Cysts/diagnosis ; Colloid Cysts/pathology ; Colloid Cysts/secondary ; Colloid Cysts/surgery ; Diagnosis, Differential ; Humans ; Kidney Neoplasms/pathology ; Kidney Neoplasms/surgery ; Male ; Middle Aged ; Third Ventricle/pathology ; Third Ventricle/surgery ; Treatment Outcome
Language	English
Publishing date	2013-04
Publishing country	Austria
Document type	Case Reports ; Letter
ZDB-ID	80010-7
ISSN	0942-0940 ; 0001-6268
ISSN (online)	0942-0940
ISSN	0001-6268
DOI	10.1007/s00701-013-1646-8
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Article ; Online: Methodology and reporting of meta-analyses in the neurosurgical literature. Response.

Klimo, Paul / Thompson, Clinton J / Ragel, Brian T / Boop, Frederick A

Journal of neurosurgery

2014 Volume 120, Issue 4, Page(s) 794–795

MeSH term(s)	Humans ; Meta-Analysis as Topic ; Neurosurgery ; Publishing/standards
Language	English
Publishing date	2014-04
Publishing country	United States
Document type	Comment ; Editorial
ZDB-ID	3089-2
ISSN	1933-0693 ; 0022-3085
ISSN (online)	1933-0693
ISSN	0022-3085
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Article ; Online: Severe Pediatric Head Injury During the Iraq and Afghanistan Conflicts.

Klimo, Paul / Ragel, Brian T / Jones, G Morgan / McCafferty, Randall

Neurosurgery

2015 Volume 77, Issue 1, Page(s) 1–7; discussion 7

Abstract: Background: Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented.: Objective: To describe the ... ...

Abstract	Background: Much has been written about injuries sustained by US and coalition soldiers during the Global War on Terrorism campaigns. However, injuries to civilians, including children, have been less well documented. Objective: To describe the epidemiologic features and outcomes associated with isolated severe head injury in children during Operations Enduring Freedom and Iraqi Freedom (OEF and OIF). Methods: A retrospective review of children (<18 years old) in the Joint Theater Trauma Registry with isolated head injury (defined as an Abbreviated Injury Score Severity Code >3) and treated at a US combat support hospital in Iraq or Afghanistan (2004-2012). The primary outcome was in-hospital mortality. Results: We identified 647 children with severe isolated head injuries: 337 from OEF, 268 from OIF, and 42 nontheater specific. Most were boys (76%; median age = 8 years). Penetrating injuries were most common (60.6%). Overall, 330 (51%) children underwent a craniotomy/craniectomy; 156 (24.1%) succumbed to their injuries. Admission Glasgow Coma Score was predictive of survival among the entire cohort and each of the individual conflicts. Male sex also significantly increased the odds of survival for the entire group and OEF, but not for OIF. Closed-head injury improved the predictive ability of our model but did not reach statistical significance as an independent factor. Conclusion: This is the largest study of combat-related isolated head injuries in children. Admission Glasgow Coma Score and male sex were found to be predictive of survival. Assets to comprehensively care for the pediatric patient should be established early in future conflicts.
MeSH term(s)	Adolescent ; Afghan Campaign 2001- ; Afghanistan ; Child ; Child, Preschool ; Craniocerebral Trauma/epidemiology ; Female ; Hospital Mortality ; Humans ; Iraq ; Iraq War, 2003-2011 ; Male ; Retrospective Studies ; War-Related Injuries/epidemiology
Language	English
Publishing date	2015-04-21
Publishing country	United States
Document type	Journal Article
ZDB-ID	135446-2
ISSN	1524-4040 ; 0148-396X
ISSN (online)	1524-4040
ISSN	0148-396X
DOI	10.1227/NEU.0000000000000743
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Article ; Online: Decompressive craniectomy in a neurologically devastated pregnant woman to maintain fetal viability.

Whitney, Nathaniel / Raslan, Ahmed M / Ragel, Brian T

Journal of neurosurgery

2012 Volume 116, Issue 3, Page(s) 487–490

Abstract: Severe traumatic brain injury (TBI) in pregnant women can result in devastating outcomes for both the mother and the fetus. Historically, there has been concern regarding the issues involved when the fetus is not yet viable outside the womb. Currently, ... ...

Abstract	Severe traumatic brain injury (TBI) in pregnant women can result in devastating outcomes for both the mother and the fetus. Historically, there has been concern regarding the issues involved when the fetus is not yet viable outside the womb. Currently, the ability to treat severe TBI with aggressive management of intracranial pressure (ICP) has led to the possibility of sustaining maternal life until the fetus is of a viable age and can be delivered. The authors present the case of a young woman 21 weeks pregnant with a severe TBI (Glasgow Coma Scale Score 3) in whom safe medical ICP management became ineffective. A decompressive craniectomy was performed to obviate the need for aggressive medical management of elevated ICP using fetal-toxic medications, and thus providing the fetus the best chance of continued in utero development until a viable gestational age was reached.
MeSH term(s)	Adult ; Brain Injuries/complications ; Decompression, Surgical ; Decompressive Craniectomy/methods ; Female ; Fetal Viability/physiology ; Glasgow Coma Scale ; Humans ; Intracranial Hypertension/surgery ; Pregnancy ; Pregnancy Complications/etiology ; Pregnancy Complications/surgery ; Pregnancy Trimester, Second ; Tomography, X-Ray Computed ; Treatment Outcome ; Young Adult
Language	English
Publishing date	2012-03
Publishing country	United States
Document type	Case Reports ; Journal Article
ZDB-ID	3089-2
ISSN	1933-0693 ; 0022-3085
ISSN (online)	1933-0693
ISSN	0022-3085
DOI	10.3171/2011.11.JNS11707
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Article: Imaging characteristic analysis of metastatic spine lesions from breast, prostate, lung, and renal cell carcinomas for surgical planning: Osteolytic versus osteoblastic.

Reddington, Justin A / Mendez, Gustavo A / Ching, Alex / Kubicky, Charlotte Dai / Klimo, Paul / Ragel, Brian T

Surgical neurology international

2016 Volume 7, Issue Suppl 13, Page(s) S361–5

Abstract: Background: Surgeons treating metastatic spine disease can use computed tomography (CT) imaging to determine whether lesions are osteolytic, osteoblastic, or mixed. This enables treatment that considers the structural integrity of the vertebral body (VB) ...

Abstract	Background: Surgeons treating metastatic spine disease can use computed tomography (CT) imaging to determine whether lesions are osteolytic, osteoblastic, or mixed. This enables treatment that considers the structural integrity of the vertebral body (VB), which is impaired with lytic lesions but not blastic lesions. The authors analyzed CT imaging characteristics of spine metastasis from breast, lung, prostate, and renal cell carcinomas (RCCs) to determine the metastasis patterns of each of these common tumors. Methods: The authors identified patients with metastatic spine disease treated during a 3-year period. Variables studied included age, sex, and cancer type. Lesions from breast, lung, prostate, and RCC primary lesions were selected for imaging analysis. Results: Sixty-six patients were identified: 17 had breast metastasis, 14 prostate, 18 lung, and 17 RCC. Breast cancer metastasis involved 33% of VBs with 56%, 20%, and 24% osteolytic, osteoblastic, and mixed, respectively. Prostate cancer metastasis involved 35% of VBs with 14%, 62%, and 24% osteolytic, osteoblastic, and mixed, respectively. Lung cancer metastasis involved 13% of VBs with 64%, 33%, and 3% osteolytic, osteoblastic, and mixed, respectively. RCC metastasis involved 11% of VBs with 91%, 7%, and 2% osteolytic, osteoblastic, and mixed lesions, respectively. Conclusions: To improve surgical planning, we advocate the use of CT prior to surgery to evaluate whether spine metastases are osteolytic or osteoblastic. In cases of osteolytic lesions, the concern is of segmental instability requiring reconstruction and the risk for screw pull out should instrumentation be considered. In cases of osteoblastic lesions, surgeons should consider debulking dense bone.
Language	English
Publishing date	2016-05-17
Publishing country	United States
Document type	Journal Article
ISSN	2229-5097
ISSN	2229-5097
DOI	10.4103/2152-7806.182549
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Article ; Online: The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries.

Brockmeyer, Douglas L / Ragel, Brian T / Kestle, John R W

Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery

2012 Volume 28, Issue 5, Page(s) 699–705

Abstract: Purpose: Cervical spine clearance in severely injured children after trauma is often difficult because of unique injury patterns, concerns about radiation exposure to growing tissue, and unfamiliarity with unstable cervical injuries. We prospectively ... ...

Abstract	Purpose: Cervical spine clearance in severely injured children after trauma is often difficult because of unique injury patterns, concerns about radiation exposure to growing tissue, and unfamiliarity with unstable cervical injuries. We prospectively assessed the utility of four radiographic modalities to clear the cervical spine in children after severe trauma. Methods: Twenty-four comatose, intubated children with severe traumatic injuries underwent radiographic evaluation to clear the cervical spine. Each patient had plain radiographs, flexion-extension radiographs under fluoroscopy, computed tomography (CT), and magnetic resonance (MR) imaging within 10 days of admission. Patients underwent cervical spine flexion-extension radiographs 2-3 months after trauma to detect late instability. Sensitivity and specificity for each radiographic modality was determined. Results: Plain cervical spine radiographs demonstrated sensitivity of 100% and specificity of 95%; flexion-extension radiographs had “indeterminate” sensitivity and specificity of 100%. For CT, sensitivity was 100% and specificity was 95%, and for MR imaging, sensitivity was 100% and specificity was 74%. Conclusions: There was a low prevalence of cervical instability in this high-risk group. Plain radiographs, flexion-extension radiographs, and CT all had high sensitivities and specificities. MR imaging had a high false-positive rate, making it sensitive but not specific. The data support using either CT or plain radiographs as the initial cervical spine screening study, but CT is recommended because of its superior ability to detect critical injuries. To definitively rule out ligamentous instability after a negative screening CT scan or cervical spine X-ray, these data support using flexion-extension X-rays with fluoroscopy and not MR imaging.
MeSH term(s)	Adolescent ; Cervical Vertebrae/diagnostic imaging ; Cervical Vertebrae/injuries ; Child ; Child, Preschool ; Female ; Humans ; Infant ; Injury Severity Score ; Joint Instability/diagnostic imaging ; Magnetic Resonance Imaging/methods ; Magnetic Resonance Imaging/standards ; Male ; Pilot Projects ; Prognosis ; Prospective Studies ; Spinal Injuries/diagnostic imaging ; Tomography, X-Ray Computed/methods ; Tomography, X-Ray Computed/standards ; Trauma Severity Indices
Language	English
Publishing date	2012-03-01
Publishing country	Germany
Document type	Journal Article ; Research Support, U.S. Gov't, Non-P.H.S.
ZDB-ID	605988-0
ISSN	1433-0350 ; 0302-2803 ; 0256-7040
ISSN (online)	1433-0350
ISSN	0302-2803 ; 0256-7040
DOI	10.1007/s00381-012-1696-x
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