Julie G Pilitsis

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• Berwal, D., Quintero, A., Telkes, I., DiMarzio, M., Harland, T., Paniccioli, S., Dalfino, J., Iyassu, Y., McLaughlin, B. L., & Pilitsis, J. G. (2024). Improved Selectivity in Eliciting Evoked Electromyography Responses With High-Resolution Spinal Cord Stimulation. Neurosurgery. doi:10.1227/neu.0000000000002878
• Elliott, T., Merlano Gomez, M., Morris, D., Wilson, C., & Pilitsis, J. G. (2024). A scoping review of mechanisms of auricular acupuncture for treatment of pain. Postgraduate Medicine, 1-11. doi:10.1080/00325481.2024.2333232
• Deer, T., Pope, J., Falowski, S., Pilitsis, J., Hunter, C., Burton, A., Connolly, A., & Verrills, P. (2023). Clinical Longevity of 106,462 Rechargeable and Primary Cell Spinal Cord Stimulators: Real World Study in the Medicare Population. Neuromodulation, 26(1). doi:10.1016/j.neurom.2022.04.046
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  Introduction: Spinal cord stimulators (SCS) are available with either primary cell (PC) or rechargeable cell (RC) batteries. Although RC systems are proposed to have a battery longevity upward of nine years, in comparison with four years for PC systems, there are few studies of longevity of SCS in the real world. Materials and Methods: This was an observational, nonrandomized, retrospective study of Medicare beneficiaries who received neurostimulator implants in the outpatient hospital. This study used Medicare fee-for-service claims data from 2013 to 2020. The clinical longevity of the implantable pulse generator (IPG), defined as the duration from implant until removal for any reason, was compared between PC and RC devices. Life distribution analysis was used to approximate device lifespan. The secondary analysis separated removals into explant or replacements. The statistics were adjusted for relevant clinical covariates. Results: A total of 25,856 PC and 79,606 RC systems were included in the study. At seven years after implant, 53.8% of PC IPGs and 55.0% of RC IPGs remained in use. The life distribution modeling analysis projected a median lifespan of 8.2 years for PC and 9.0 years for RC devices. The rate of explant was lower for PC devices (19.2%) than for RC devices (22.0%, hazard ratio (HR) = 0.96, p = 0.082), whereas the rate of replacements was higher for PC devices (33.7%) than for RC devices (29.5%, HR = 1.31, p < 0.001). An analysis of the battery type used in device replacements showed an increasing adoption of PC devices over time. Conclusions: This large, retrospective, real-world analysis of Medicare claims data demonstrated that the clinical longevity of neurostimulator devices is similar for PC and RC batteries. In the past, clinicians may have defaulted to RC devices based on the assumption that they provided extended battery life. Considering this longevity data, clinicians should now consider the choice between PC and RC devices based on other individual factors pertinent to the patient experience and not on purported longevity claims.
• Mahoney-Rafferty, E., Tucker, H., Akhtar, K., Herlihy, R., Audil, A., Shah, D., Gupta, M., Kochman, E., Feustel, P., Molho, E., Pilitsis, J., & Shin, D. (2023). Assessing the Location, Relative Expression and Subclass of Dopamine Receptors in the Cerebellum of Hemi-Parkinsonian Rats. Neuroscience, 521. doi:10.1016/j.neuroscience.2023.03.020
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  Parkinson's Disease (PD) is a neurodegenerative disease with loss of dopaminergic neurons in the nigrostriatal pathway resulting in basal ganglia (BG) dysfunction. This is largely why much of the preclinical and clinical research has focused on pathophysiological changes in these brain areas in PD. The cerebellum is another motor area of the brain. Yet, if and how this brain area responds to PD therapy and contributes to maintaining motor function fidelity in the face of diminished BG function remains largely unanswered. Limited research suggests that dopaminergic signaling exists in the cerebellum with functional dopamine receptors, tyrosine hydroxylase (TH) and dopamine transporters (DATs); however, much of this information is largely derived from healthy animals and humans. Here, we identified the location and relative expression of dopamine 1 receptors (D1R) and dopamine 2 receptors (D2R) in the cerebellum of a hemi-parkinsonian male rat model of PD. D1R expression was higher in PD animals compared to sham animals in both hemispheres in the purkinje cell layer (PCL) and granule cell layer (GCL) of the cerebellar cortex. Interestingly, D2R expression was higher in PD animals than sham animals mostly in the posterior lobe of the PCL, but no discernible pattern of D2R expression was seen in the GCL between PD and sham animals. To our knowledge, we are the first to report these findings, which may lay the foundation for further interrogation of the role of the cerebellum in PD therapy and/or pathophysiology.
• Nuzov, N., Bhusal, B., Henry, K., Jiang, F., Vu, J., Rosenow, J., Pilitsis, J., Elahi, B., & Golestanirad, L. (2023). Artifacts Can Be Deceiving: The Actual Location of Deep Brain Stimulation Electrodes Differs from the Artifact Seen on Magnetic Resonance Images. Stereotactic and Functional Neurosurgery, 101(1). doi:10.1159/000526877
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  Introduction: Deep brain stimulation (DBS) is a common treatment for a variety of neurological and psychiatric disorders. Recent studies have highlighted the role of neuroimaging in localizing the position of electrode contacts relative to target brain areas in order to optimize DBS programming. Among different imaging methods, postoperative magnetic resonance imaging (MRI) has been widely used for DBS electrode localization; however, the geometrical distortion induced by the lead limits its accuracy. In this work, we investigated to what degree the difference between the actual location of the lead's tip and the location of the tip estimated from the MRI artifact varies depending on the MRI sequence parameters such as acquisition plane and phase encoding direction, as well as the lead's extracranial configuration. Accordingly, an imaging technique to increase the accuracy of lead localization was devised and discussed. Methods: We designed and constructed an anthropomorphic phantom with an implanted DBS system following 18 clinically relevant configurations. The phantom was scanned at a Siemens 1.5 Tesla Aera scanner using a T1MPRAGE sequence optimized for clinical use and a T1TSE sequence optimized for research purposes. We varied slice acquisition plane and phase encoding direction and calculated the distance between the caudal tip of the DBS lead MRI artifact and the actual tip of the lead, as estimated from MRI reference markers. Results: Imaging parameters and lead configuration substantially altered the difference in the depth of the lead within its MRI artifact on the scale of several millimeters-with a difference as large as 4.99 mm. The actual tip of the DBS lead was found to be consistently more rostral than the tip estimated from the MR image artifact. The smallest difference between the tip of the DBS lead and the tip of the MRI artifact using the clinically relevant sequence (i.e., T1MPRAGE) was found with the sagittal acquisition plane and anterior-posterior phase encoding direction. Discussion/Conclusion: The actual tip of an implanted DBS lead is located up to several millimeters rostral to the tip of the lead's artifact on postoperative MR images. This distance depends on the MRI sequence parameters and the DBS system's extracranial trajectory. MRI parameters may be altered to improve this localization.
• Patel, N. P., Jameson, J., Johnson, C., Kloster, D., Calodney, A., Kosek, P., Pilitsis, J., Bendel, M., Petersen, E., Wu, C., Cherry, T., Lad, S., Yu, C., Sayed, D., Goree, J., Lyons, M. K., Sack, A., Bruce, D., Bharara, M., , Province-Azalde, R., et al. (2023). Durable responses at 24 months with high-frequency spinal cord stimulation for nonsurgical refractory back pain. Journal of Neurosurgery: Spine, 1-11. doi:10.3171/2023.9.spine23504
• Tangney, T., Heydari, E., Sheldon, B., Shetty, A., Argoff, C., Khazen, O., & Pilitsis, J. (2023). Botulinum Toxin as an Effective Treatment for Trigeminal Neuralgia in Surgical Practices. Stereotactic and Functional Neurosurgery, 100(5-6). doi:10.1159/000526053
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  Background: Trigeminal neuralgia (TN) is a common cause of craniofacial pain with many medical and surgical therapies, all of which are imperfect. We examine the use of botulinum toxin type-A (BTX-A) as an intermediary approach in surgical practices. Methods: We retrospectively identified TN patients seen by both pain neurology and neurosurgery at our center. Demographics were collected. Pain intensity was assessed using the numerical rating scale (NRS) and compared from baseline to after BTX-A treatment via paired t test. Responder status was assessed, and success of BTX-A was determined for each cohort. Doses of common medications were compared between baseline visit and the most recent BTX-A administration visit. Results: Thirty-one patients underwent BTX-A therapy for TN, 24 (77%) female and 7 (23%) male. Mean age was 62.5 ± 3.1 years and 29 (94%) identified as white. When divided into cohorts according to indication, 11 (35%) failed prior TN surgery, 9 (29%) either declined surgery or were poor surgical candidates, 4 (13%) had multiple sclerosis, 4 (13%) had trigeminal neuropathic pain, and 3 (10%) had atypical TN with pain in additional dermatomes outside the trigeminal distribution. Significant reductions in NRS from baseline to following initial BTX-A treatment were seen in the declined/high risk for surgery (p = 0.004) and those who failed prior TN surgery (p = 0.035) groups. No significant variation in demographics was found between any two groups (p > 0.05 for all). Finally, there was no significant reduction in total daily dose of gabapentin, carbamazepine, oxcarbazepine, baclofen, or lamotrigine in BTX-A responders (p > 0.05 for all). Discussion: Indication is an important predictor for BTX-A, with classical TN patients exhibiting the highest response rates. This research highlights the viability of BTX-A as an important tool in the arsenal of providers seeking to treat TN in a minimally invasive manner.
• Barrie, U., Williams, M., Nguyen, M., Kenfack, Y., Mason, H., Ata, A., Aoun, S., & Pilitsis, J. (2022). Characteristics of graduating medical students interested in neurosurgery with intention to practice in underserved areas: Implications for residency programs. Clinical Neurology and Neurosurgery, 218. doi:10.1016/j.clineuro.2022.107293
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  Objective: It is of paramount importance that the United States (U.S.) physician and surgical workforce reflects its changing population demographics. The authors characterized factors contributing to graduating medical students’ decision to pursue a residency in Neurosurgery to assess opportunities for recruitment and retainment of graduates interested in working with underserved populations. Methods: Data from the Association of American Medical Colleges (AAMC) Student Record System (SRS), and the AAMC Graduation Questionnaire (GQ) were collected on a national cohort of U.S. medical students from 2012 through 2017. Data including self-reported sex, race/ethnicity, age at matriculation, degree program, intention to practice in underserved area, total debt, scholarships, volunteer activities and medical electives was analyzed using chi-squared tests and multivariate logistic regression models. Results: The study included 48,096 graduating medical students surveyed by GQ and SRS, 607 (1.26%) of whom reported an intention to pursue Neurosurgery (Neurosurgery cohort). Compared to students pursuing other specialties, the Neurosurgery cohort had fewer students identify as female (18.95% vs. 48.18%, p < 0.001), and report an intention to work with underserved populations (11.37% vs. 26.37%, p < 0.001). In addition, Black/African-American students were significantly more like to indicate intention to pursue Neurosurgery compared to White students (aOR=1.51, 95% CI:1.01–2.24). Moreover, within the Neurosurgery cohort, Black/African-American (aOR=7.66, 95% CI:2.87–20.45), Hispanic (aOR=4.50, 95% CI:1.40–14.51) and female students (aOR=2.44, 95% CI:1.16–5.12) were more likely to report an intention to practice in underserved urban and rural areas, compared to their peers. Conclusions: Our study identified several key demographic and academic factors influencing intention to pursue a neurosurgical career, and work with underserved populations. Our data provides an opportunity for further discussions on the residency selection process and seeks to empower residency programs to diversify the neurosurgical workforce, tackle health disparities and improve patient care for the entire US population.
• Bondoc, M., Hancu, M., Dimarzio, M., Sheldon, B., Shao, M., Khazen, O., & Pilitsis, J. (2022). Age as an Independent Predictor of Adult Spinal Cord Stimulation Pain Outcomes. Stereotactic and Functional Neurosurgery, 100(1). doi:10.1159/000517426
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  Introduction: Spinal cord stimulation (SCS) is an efficacious chronic pain treatment most commonly used in middle-aged patients. Results from previous studies that investigated SCS′ effects in older patient populations have been equivocal. We examine whether SCS outcomes correlate with age. Methods: We retrospectively examined prospectively collected outcomes from 189 patients who underwent SCS at Albany Medical Center between 2012 and 2020. The patients completed the Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS) preoperatively and 1 year postoperatively. The mean percent change in each outcome was determined and compared via a regression analysis to determine relationships between patient age and each respective outcome metrics. Demographics were compared between patients aged under 65 versus those aged 65 and older via χ2 tests. Results: All subjects demonstrated the expected improvement on NRS, BDI, PCS, and MPQ from baseline to 1-year follow-up, with several demonstrating statistically significant changes: NRS-worst pain (18.66%, p < 0.001), NRS-least pain (26.9%, p < 0.001), NRS-average pain (26.9%, p < 0.01), NRS-current pain (26.4%, p < 0.001), ODI (19.6%, p < 0.001), PCS (29.8%, p < 0.001), and MPQ (29.4%, p < 0.001). There was no significant difference between patients aged under 65 versus those aged 65 and older based on lead type (p = 0.454). Six patients (3.1%) had lead migration, one of whom was 65 or older. Regression analysis revealed improvements in MPQ-sensory and MPQ-affective scores as age increased (p < 0.001, R2 = 0.09; p = 0.046, R2 = 0.05, respectively). Age did not correlate with NRS, ODI, BDI, or PCS. Diagnosis, spinal level of SCS, and lead type were not found to influence any respective outcome measure based on covariate analysis. Conclusion: This study represents the largest study where age was correlated to specific pain, depression, and disability outcomes following SCS. We provide evidence that SCS outcomes are equivalent, or better, in older patients following SCS. Based on these findings, SCS is a viable option for treatment of chronic pain in elderly patient populations.
• Harland, T., Gillogly, M., Khazen, O., Gajjar, A., Nabage, M., Trujillo, F., DiMarzio, M., & Pilitsis, J. (2022). A Pilot Study Comparing Algorithmic Adaptive Conventional Stimulation with High-Dose Stimulation in Chronic Pain Patients. World Neurosurgery, 167. doi:10.1016/j.wneu.2022.08.096
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  Introduction: Spinal cord stimulation is an effective method of treatment for chronic pain. We previously showed that programming using accelerometry was advantageous for paresthesia-based stimulation. However, programming can be labor intensive. Objective: Here we focus on standardized programming for both accelerometer-based paresthesia-induced programming (termed “shuffle”) and high-dose (HD) subthreshold programming with stimulation delivered over the T9-10 interspace. Methods: In this prospective cross-over study, patients received 4 weeks of shuffle programming and 4 weeks of HD programming in a randomized order. In both intervals, contacts overlying T9-10 were programmed. Pain scales with measurements of activity and sleep were collected at the end of each study arm and compared with preoperative baseline scores. Results: Twelve patients were enrolled, with 10 patients completing this study. Compared with baseline, during the HD study period, significant improvements were seen in worst pain of week (P = 0.03) and current pain (P = 0.04) as rated on Numeric Rating Scale scores and walking on the Activity Test (P = 0.012). No difference was seen from baseline compared with shuffle stimulation or in shuffle stimulation compared with HD stimulation. Conclusion: In this pilot study, we demonstrated that HD stimulation at T9-10 is superior to algorithmic programming of paresthesia-based stimulation. These results compared with our previous work with shuffle suggest that paresthesia-based stimulation may necessitate stimulation of additional contact locations and additional programming to optimize. This algorithmic programming of paresthesia-based stimulation continues to warrant exploration.
• Kapural, L., Jameson, J., Johnson, C., Kloster, D., Calodney, A., Kosek, P., Pilitsis, J., Bendel, M., Petersen, E., Wu, C., Cherry, T., Lad, S. P., Yu, C., Sayed, D., Goree, J., Lyons, M. K., Sack, A., Bruce, D., Rubenstein, F., , Province-Azalde, R., et al. (2022). Treatment of nonsurgical refractory back pain with high-frequency spinal cord stimulation at 10 kHz: 12-month results of a pragmatic, multicenter, randomized controlled trial. Journal of Neurosurgery: Spine, 37(2), 188-199. doi:10.3171/2021.12.spine211301
• Pilitsis, J., & Rosenow, J. (2022). Advances in Pain Management. Neurosurgery Clinics of North America, 33(3). doi:10.1016/j.nec.2022.03.002
• Sheldon, B., DiMarzio, M., Chung, S., Tram, J., Khazen, O., Staudt, M., Bondoc, M., & Pilitsis, J. (2022). Association of Outcomes of Spinal Cord Stimulation for Chronic Low Back Pain and Psoas Measurements Based on Size of Iliopsoas Muscles. Neuromodulation, 25(1). doi:10.1111/ner.13375
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  Introduction: Patients experience variable long-term improvement in chronic back pain despite successful spinal cord stimulation (SCS) trials. Iliopsoas (IP) size has been shown to differ between patients with low back pain and healthy controls. In this study, we examine whether the IP muscle cross-sectional area (CSA) is associated with SCS outcomes. Materials and Methods: We examined patients for whom we had lumbar MRIs 6.3 years prior to SCS and baseline and one-year outcome data. Percent change from baseline to one year was calculated for Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), Pain Catastrophizing Scale (PCS), and McGill Pain Questionnaire (MPQ). Correlations between IP muscle CSA, ratio of iliopsoas muscle size to the vertebral body area (P/VBA), and the ratio of iliopsoas muscle size to BMI (P/BMI) were examined. Sex differences were considered. Results: A total of 73 subjects were included in this study, including 30 females and 43 males. Males had significantly larger IP (males 15.70 ± 0.58, females 9.72 ± 0.43; p < 0.001), P/VBA (males 1.00 ± 0.04, females 0.76 ± 0.03; p < 0.001), and P/BMI ratio (males 0.51 ± 0.02, females 0.32 ± 0.01; p < 0.001) than females. In females, P/VBA predicted NRS worst pain scores (β = 0.82, p = 0.004, r2 = 0.55) and BDI (β = 0.59, p = 0.02, r2 = 0.24). In males, P/BMI was a significant predictor of BDI outcome scores (β = 0.45, p = 0.03, r2 = 0.16). Males who had more muscle mass measured by iliopsoas size had more depression as measured using BDI (p = 0.03, r = 0.61). Females with less muscle mass measured by P/VBA also experienced more depression (p = 0.02, r = 0.74). Conclusions: Our study showed that psoas measurements correlated with various pain outcomes specifically. P/VBA was most predictive in females and P/BMI in males. Depression correlated with P/BMI, reinforcing the complex relationship between depression and constant chronic pain. Tertile analyses further showed a relationship between iliopsoas CSA and depression in males and females. We provide preliminary data of sex-specific psoas measurements as a risk factor for worse SCS outcomes.
• Vu, J., Bhusal, B., Nguyen, B., Sanpitak, P., Nowac, E., Pilitsis, J., Rosenow, J., & Golestanirad, L. (2022). A comparative study of RF heating of deep brain stimulation devices in vertical vs. horizontal MRI systems. PLoS ONE, 17(12). doi:10.1371/journal.pone.0278187
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  The majority of studies that assess magnetic resonance imaging (MRI) induced radiofrequency (RF) heating of the tissue when active electronic implants are present have been performed in horizontal, closed-bore MRI systems. Vertical, open-bore MRI systems have a 90º rotated magnet and a fundamentally different RF coil geometry, thus generating a substantially different RF field distribution inside the body. Little is known about the RF heating of elongated implants such as deep brain stimulation (DBS) devices in this class of scanners. Here, we conducted the first large-scale experimental study investigating whether RF heating was significantly different in a 1.2 T vertical field MRI scanner (Oasis, Fujifilm Healthcare) compared to a 1.5 T horizontal field MRI scanner (Aera, Siemens Healthineers). A commercial DBS device mimicking 30 realistic patient-derived lead trajectories extracted from postoperative computed tomography images of patients who underwent DBS surgery at our institution was implanted in a multi-material, anthropomorphic phantom. RF heating around the DBS lead was measured during four minutes of high-SAR RF exposure. Additionally, we performed electromagnetic simulations with leads of various internal structures to examine this effect on RF heating. When controlling for RMS B1+, the temperature increase around the DBS lead-tip was significantly lower in the vertical scanner compared to the horizontal scanner (0.33 ± 0.24ºC vs. 4.19 ± 2.29ºC). Electromagnetic simulations demonstrated up to a 17-fold reduction in the maximum of 0.1g-averaged SAR in the tissue surrounding the lead-tip in the vertical scanner compared to the horizontal scanner. Results were consistent across leads with straight and helical internal wires. Radiofrequency heating and power deposition around the DBS lead-tip were substantially lower in the 1.2 T vertical scanner compared to the 1.5 T horizontal scanner. Simulations with different lead structures suggest that the results may extend to leads from other manufacturers.
• Li, G., Patel, N., Burdette, E., Pilitsis, J., Su, H., & Fischer, G. (2021). A Fully Actuated Robotic Assistant for MRI-Guided Precision Conformal Ablation of Brain Tumors. IEEE/ASME Transactions on Mechatronics, 26(1). doi:10.1109/TMECH.2020.3012903
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  This article reports the development of a fully actuated robotic assistant for magnetic resonance imaging (MRI) guided precision conformal ablation of brain tumors using an interstitial high-intensity needle-based therapeutic ultrasound ablator probe. The robot is designed with an eight degree-of-freedom (8-DOF) remote center of motion manipulator driven by piezoelectric actuators, five for aligning the ultrasound thermal ablator to the target lesions, and three for inserting and orienting the ablator and its cannula to generate a desired ablation profile. The 8-DOF fully actuated robot can be operated in the scanner bore during imaging; thus, alleviating the need for moving the patient in or out of the scanner during the procedure, and therefore potentially reducing the procedure time and streamlining the workflow. The free space positioning accuracy of the system is evaluated with the OptiTrack motion capture system, demonstrating the root-mean-square (RMS) error of the tip position to be 1.11 ± 0.43 mm. The system targeting accuracy in MRI is assessed with phantom studies, indicating the RMS errors of the tip position to be 1.45 ± 0.66 mm and orientation to be 1.53± 0.69. The feasibility of the system to perform thermal ablation is validated through a preliminary ex-vivo tissue study with position error less than 4.3 mm and orientation error less than 4.3°.
• Raslan, A., Ben-Haim, S., Falowski, S., Machado, A., Miller, J., Pilitsis, J., Rosenberg, W., Rosenow, J., Sweet, J., Viswanathan, A., Winfree, C., & Schwalb, J. (2021). Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Neuroablative Procedures for Patients with Cancer Pain. Neurosurgery, 88(3). doi:10.1093/neuros/nyaa527
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  BACKGROUND: Managing cancer pain once it is refractory to conventional treatment continues to challenge caregivers committed to serving those who are suffering from a malignancy. Although neuromodulation has a role in the treatment of cancer pain for some patients, these therapies may not be suitable for all patients. Therefore, neuroablative procedures, which were once a mainstay in treating intractable cancer pain, are again on the rise. This guideline serves as a systematic review of the literature of the outcomes following neuroablative procedures. OBJECTIVE: To establish clinical practice guidelines for the use of neuroablative procedures to treat patients with cancer pain. METHODS: A systematic review of neuroablative procedures used to treat patients with cancer pain from 1980 to April 2019 was performed using the United States National Library of Medicine PubMed database, EMBASE, and Cochrane CENTRAL. After inclusion criteria were established, full text articles that met the inclusion criteria were reviewed by 2 members of the task force and the quality of the evidence was graded. RESULTS: In total, 14 646 relevant abstracts were identified by the literature search, from which 189 met initial screening criteria. After full text review, 58 of the 189 articles were included and subdivided into 4 different clinical scenarios. These include unilateral somatic nociceptive/neuropathic body cancer pain, craniofacial cancer pain, midline subdiaphragmatic visceral cancer pain, and disseminated cancer pain. Class II and III evidence was available for these 4 clinical scenarios. Level III recommendations were developed for the use of neuroablative procedures to treat patients with cancer pain. CONCLUSION: Neuroablative procedures may be an option for treating patients with refractory cancer pain. Serious adverse events were reported in some studies, but were relatively uncommon. Improved imaging, refinements in technique and the availability of new lesioning modalities may minimize the risks of neuroablation even further. The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/guidelines-on-neuroablative-procedures-patients-wi.
• Staudt, M., Telkes, I., & Pilitsis, J. (2021). Achieving optimal outcomes with deep brain stimulation for posttraumatic stress disorder. Journal of Neurosurgery, 134(6). doi:10.3171/2020.5.JNS201127
• Williams, M., Varelas, E., Olmsted, Z., Sheldon, B., Khazen, O., DiMarzio, M., & Pilitsis, J. (2021). Can dogs and cats really help our spinal cord stimulation patients?. Clinical Neurology and Neurosurgery, 208. doi:10.1016/j.clineuro.2021.106831
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  Objectives: Pet ownership has been shown to decrease morbidity and mortality in several aspects of health but has not been studied in chronic pain patients. We evaluate whether subjects who underwent spinal cord stimulation (SCS) and own a pet have improved outcomes compared to non-pet owners. Methods: After obtaining IRB approval, we re-contacted 38 subjects who underwent SCS surgery with preoperative and 1-year postoperative data on Numerical Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck Depression Inventory (BDI), and Pain Catastrophizing scale (PCS). We examined influence of pets and pet ownership-specific behaviors on improvement in SCS outcomes. Results: Patients included 24 males/14 females with a mean age of 59.9 ± 11.5 years. At mean follow-up of 12.2 months (range 10–14), there were improvements in NRS, ODI, BDI, PCS and MPQ. Twenty subjects owned pets and 18 did not; all believed pet ownership could improve health. Pet owners improved more on NRS-right now (p = 0.05) and BDI (p = 0.05), and were more satisfied with SCS (p = 0.04). No significant improvement was seen in ODI, MPQ, or PCS. However, PCS did improve in pet owners who exercised their pet (PCS-total, p < 0.01; PCS-helplessness, p < 0.01; PCS-rumination, p = 0.05; PCS-magnification, p = 0.02). Conclusions: We provide preliminary evidence that pet ownership is associated with improved pain, depression and SCS satisfaction. Exercising with a pet also appears to be beneficial in limiting pain catastrophizing. Pets show promise as a novel means to improve patient SCS outcomes.
• Custozzo, A., DiMarzio, M., & Pilitsis, J. (2020). Addressing Parkinson Disease–Related Pain with Deep Brain Stimulation. World Neurosurgery, 135. doi:10.1016/j.wneu.2019.12.140
• Patel, N., Nycz, C., Carvalho, P., Gandomi, K., Gondokaryono, R., Li, G., Heffter, T., Burdette, E., Pilitsis, J., & Fischer, G. (2020). An Integrated Robotic System for MRI-Guided Neuroablation: Preclinical Evaluation. IEEE Transactions on Biomedical Engineering, 67(10). doi:10.1109/TBME.2020.2974583
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  Objective: Treatment of brain tumors requires high precision in order to ensure sufficient treatment while minimizing damage to surrounding healthy tissue. Ablation of such tumors using needle-based therapeutic ultrasound (NBTU) under real-time magnetic resonance imaging (MRI) can fulfill this need. However, the constrained space and strong magnetic field in the MRI bore restricts patient access limiting precise placement of the NBTU ablation tool. A surgical robot compatible with use inside the bore of an MRI scanner can alleviate these challenges. Methods: We present preclinical trials of a robotic system for NBTU ablation of brain tumors under real-time MRI guidance. The system comprises of an updated robotic manipulator and corresponding control electronics, the NBTU ablation system and applications for planning, navigation and monitoring of the system. Results: The robotic system had a mean translational and rotational accuracy of 1.39 ± 0.64 mm and 1.27 ± \;\text{0.56}^{\circ in gelatin phantoms and 3.13 ± 1.41 mm and 5.58 ± \;\text{3.59}^{\circ in 10 porcine trials while causing a maximum reduction in signal to noise ratio (SNR) of 10.3%. Conclusion: The integrated robotic system can place NBTU ablator at a desired target location in porcine brain and monitor the ablation in realtime via magnetic resonance thermal imaging (MRTI). Significance: Further optimization of this system could result in a clinically viable system for use in human trials for various diagnostic or therapeutic neurosurgical interventions.
• Entezami, P., Gooch, M. R., Gooch, M., Adepoju, A., Pilitsis, J. G., Pilitsis, J., Kenning, T. J., Kenning, T., Boulos, A. S., Boulos, A., Semenoff, D. L., & Semenoff, D. (2019). Commentary: The History of Neurosurgery at Albany Medical College and Albany Medical Center Hospital, Albany, New York. Clinical Neurosurgery, 85(1). doi:10.1093/neuros/nyz101
• Hwang, R., Sukul, V., Collison, C., Prusik, J., & Pilitsis, J. (2019). A Novel Approach to Avoid Baclofen Withdrawal When Faced With Infected Baclofen Pumps. Neuromodulation, 22(7). doi:10.1111/ner.12873
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  Background: Intrathecal (IT) Baclofen is beneficial for spasticity, but if pumps become infected necessitating removal, baclofen withdrawal is difficult to manage and life-threatening. Furthermore there is no consistency between dosing and severity of withdrawal. Case reports detail full baclofen withdrawal at dosages of 260 μg/day. Objective: To demonstrate that in patients on stable IT baclofen for prolonged periods, externalizing a patient's original IT pump is a safe, effective way to wean IT doses. Methods: Here, we describe a technique of continuing IT baclofen when urgent pump removal is needed. Specifically, we remove the infected pump. Then using a new or existing lumbar drain based on extent of infection, we reconnect the pump after cleaning with betadine and administer therapy externally during IT weaning. Results: Hundred forty seven baclofen pumps were implanted or replaced within four years. Infections occurred in seven patients. We utilized this technique in five of seven patients. Mean IT dose at time of explant was 400.5 ± 285.3 μg/day. We titrated the dose by 20–50% per day based on clinical response over a mean of 6.2 ± 1.3 days. The catheter was removed at bedside once weaning was complete. No patients had any signs of withdrawal, excluding minimal spasticity increases while optimizing oral treatment. Conclusion: Here, we show preliminary evidence that an externalized IT pump is an effective means of weaning IT baclofen when infection of the pump occurs. This treatment strategy warrants further investigation, but appears to be a safe and effective. Conflict of Interest: Dr. Pilitsis is a consultant for Medtronic, Boston Scientific, Nevro, Jazz Pharmaceuticals, Neurobridge Therapeutics, and Abbott and receives grant support from Medtronic, Boston Scientific, Abbott, Nevro, Jazz Pharmaceuticals, GE Global Research and NIH 1R01CA166379. She is medical advisor for Centauri and Karuna and has stock equity. Dr. Sukul receives consultant fees from Medtronic. Julia Prusik receives grant support from Jazz Pharmaceuticals.
• Lin, Y., Chen, R., Kao, T., Goddard, G., Vaisman, V., Silverman, E., Gillogly, M., Czerwinski, M., McCallum, S., & Pilitsis, J. (2019). A pilot study of a propofol sensing device for real-time analysis in surgical patients. Journal of Clinical Anesthesia, 58. doi:10.1016/j.jclinane.2019.05.025
• Sreekumari, A., Shanbhag, D., Yeo, D., Foo, T., Pilitsis, J., Polzin, J., Patil, U., Coblentz, A., Kapadia, A., Khinda, J., Boutet, A., Port, J., & Hancu, I. (2019). A deep learning-based approach to reduce rescan and recall rates in clinical MRI examinations. American Journal of Neuroradiology, 40(2). doi:10.3174/ajnr.A5926
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  BACKGROUND AND PURPOSE: MR imaging rescans and recalls can create large hospital revenue loss. The purpose of this study was to develop a fast, automated method for assessing rescan need in motion-corrupted brain series. MATERIALS AND METHODS: A deep learning- based approach was developed, outputting a probability for a series to be clinically useful. Comparison of this per-series probability with a threshold, which can depend on scan indication and reading radiologist, determines whether a series needs to be rescanned. The deep learning classification performance was compared with that of 4 technologists and 5 radiologists in 49 test series with low and moderate motion artifacts. These series were assumed to be scanned for 2 scan indications: screening for multiple sclerosis and stroke. RESULTS: The image-quality rating was found to be scan indication- And reading radiologist- dependent. Of the 49 test datasets, technologists created a mean ratio of rescans/recalls of (4.7±5.1)/(9.5±6.8) for MS and (8.6±7.7)/(1.6±1.9) for stroke. With thresholds adapted for scan indication and reading radiologist, deep learning created a rescan/recall ratio of (7.3±2.2)/(3.2±2.5) for MS, and (3.6± 1.5)/(2.8±1.6) for stroke. Due to the large variability in the technologists' assessments, it was only the decrease in the recall rate for MS, for which the deep learning algorithm was trained, that was statistically significant (P = .03). CONCLUSIONS: Fast, automated deep learning- based image-quality rating can decrease rescan and recall rates, while rendering them technologist-independent. It was estimated that decreasing rescans and recalls from the technologists' values to the values of deep learning could save hospitals $24,000/scanner/year.
• Ghoshal, G., Gee, L., Heffter, T., Williams, E., Bromfield, C., Rund, L., Ehrhardt, J., Diederich, C., Fischer, G., Pilitsis, J., & Burdette, E. (2018). A minimally invasive catheter-based ultrasound technology for therapeutic interventions in brain: Initial preclinical studies. Neurosurgical Focus, 44(2). doi:10.3171/2017.11.FOCUS17631
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  OBJECTIVE Minimally invasive procedures may allow surgeons to avoid conventional open surgical procedures for certain neurological disorders. This paper describes the iterative process for development of a catheter-based ultrasound thermal therapy applicator. METHODS Using an ultrasound applicator with an array of longitudinally stacked and angularly sectored tubular transducers within a catheter, the authors conducted experimental studies in porcine liver, in vivo and ex vivo, in order to characterize the device performance and lesion patterns. In addition, they applied the technique in a rodent model of Parkinson's disease to investigate the feasibility of its application in brain. RESULTS Thermal lesions with multiple shapes and sizes were readily achieved in porcine liver. The feasibility of catheter- based focused ultrasound in the treatment of brain conditions was demonstrated in a rodent model of Parkinson's disease. CONCLUSIONS The authors show proof of principle of a catheter-based ultrasound system that can create lesions with concurrent thermode-based measurements.
• Huang, Y., Aronson, J., Pilitsis, J., Gee, L., Durphy, J., Molho, E., & Ramirez-Zamora, A. (2018). Anatomical correlates of uncontrollable laughter with unilateral subthalamic deep brain stimulation in Parkinson's disease. Frontiers in Neurology, 9(MAY). doi:10.3389/fneur.2018.00341
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  Introduction: Subthalamic nucleus deep brain stimulation (STN-DBS) is a well-established treatment for the management of motor complications in Parkinson's disease. Uncontrollable laughter has been reported as a rare side effect of STN stimulation. The precise mechanism responsible for this unique phenomenon remains unclear. We examined in detail the DBS electrode position and stimulation parameters in two patients with uncontrollable laughter during programming after STN-DBS surgery and illustrated the anatomical correlates of the acute mood changes with STN stimulation. Case report: Unilateral STN-DBS induced uncontrollable laughter with activation of the most ventral contacts in both patients. However, the location of the electrodes responsible for this adverse effect differed between the patients. In the first patient, the DBS lead was placed more inferiorly and medially within the STN. In the second patient, the DBS lead was implanted more anteriorly and inferiorly than initially planned at the level of the substantia nigra reticulata (SNr). Conclusion: Unilateral STN-DBS can induce acute uncontrollable laughter with activation of electrodes located more anterior, medial, and inferior in relationship with the standard stereotactic STN target. We suggest that simulation of ventral and medial STN, surrounding limbic structures or the SNr, is the most plausible anatomical substrate responsible for this acute mood and behavioral change. Our findings provide insight into the complex functional neuroanatomical relationship of the STN and adjacent structures important for mood and behavior. DBS programming with more dorsal and lateral contacts within the STN should be entertained to minimize the emotional side effects.
• Haider, S., Owusu-Sarpong, S., Peris Celda, M., Wilock, M., Prusik, J., Youn, Y., & Pilitsis, J. (2017). A Single Center Prospective Observational Study of Outcomes With Tonic Cervical Spinal Cord Stimulation. Neuromodulation, 20(3). doi:10.1111/ner.12483
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  Background: Spinal cord stimulation (SCS) has been a valuable resource for the treatment of chronic, nonmalignant pain that persists in the face of maximal medical management. A recent study demonstrated efficacy of cervical SCS in a multicenter registry. Here, in our single center study, we are able to delve into patient specifics, explore outcomes with percutaneous vs. paddle implants, and examine impact of patient symptomatology. Methods: We prospectively collected data on subjects who underwent cervical SCS via numeric rating scale (NRS), McGill Pain Questionnaire, Oswestry Disability Index (ODI), and Beck Depression Inventory. Subjects completed this battery pre-operatively, at six months and at one year. Data were analyzed via repeated measures ANOVA, bivariate correlation analysis, and paired t-tests. Results: In 30 consecutive subjects, 24 had a complete data set. The diagnosis was failed neck surgery syndrome (13%), Complex regional pain syndrome (29%), and neuropathic pain (58%). Compared with baseline, NRS score significantly improved at six months (p = 0.021) and one year (p = 0.047). ODI score also improved at one year (p = 0.009). At both six months and one year, subjects with percutaneous implants reported significantly less disability on ODI (p = 0.016 and 0.034, respectively), as compared with those who received paddle implants. There was no difference in NRS score or any other outcome measure based on type of implant. Diagnosis or region of pain did not correlate with any measure of outcome. Discussion: We demonstrate that neck and arm pain can be improved with cervical SCS at six month and one-year follow-ups. Both percutaneous and paddle implants have benefit. We tend to place percutaneous implants for radicular pain and retrograde C1-2 paddles for axial pain that is ineffectively treated during the trial.
• Marola, O., Cherala, R., Prusik, J., Kumar, V., Fama, C., Wilock, M., Crimmins, J., & Pilitsis, J. (2017). BMI as a Predictor of Spinal Cord Stimulation Success in Chronic Pain Patients. Neuromodulation, 20(3). doi:10.1111/ner.12482
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  Background: Spinal cord stimulation (SCS) is an effective method of treating chronic pain. Obese patients are overrepresented in chronic pain cases. We examine the effect of body mass index (BMI) on SCS success. Methods: We prospectively follow outcome measures including visual analog score, Beck Depression Inventory (BDI), McGill Pain Questionnaire, Oswestry Disability Index (ODI), Pain Catastrophizing Scale (PCS), and the Insomnia Severity Index at baseline, six months, and one year postoperatively. Retrospectively, we examined whether our patients with a BMI above the 75th percentile (BMI ≥36.5) had worse outcomes. Results: Our analysis included thoracic and cervical SCS patients—19 with a BMI ≥36.5 and 58 with a BMI
• Peng, S., Levine, D., Ramirez-Zamora, A., Chockalingam, A., Feustel, P., Durphy, J., Hanspal, E., Novak, P., & Pilitsis, J. (2017). A Comparison of Unilateral Deep Brain Stimulation (DBS), Simultaneous Bilateral DBS, and Staged Bilateral DBS Lead Accuracies. Neuromodulation, 20(5). doi:10.1111/ner.12588
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  Background: Accuracy of lead placement within the brain can affect the outcome of deep brain stimulation (DBS) surgery. Whether performing unilateral lead implantation, simultaneous bilateral lead implantation, or staged bilateral lead implantation affects accuracy has not yet been assessed. We compare lead placement errors to evaluate whether one approach affords greater lead accuracy. Methods: We retrospectively reviewed 205 leads placed in 125 DBS surgeries. The accuracy of lead placement, defined by differences in x, y, and z coordinates and error vector magnitudes, was compared between three surgery groups: unilateral leads, bilateral leads placed simultaneously, and bilateral leads placed in staged surgeries. We also compared accuracies between first and second leads within each bilateral cohort and between second leads of the bilateral cohorts. Finally, we examined the effect of target and age on accuracy. Results: The accuracy of lead placement was comparable among unilateral, simultaneous bilateral, and staged bilateral leads. Timing of placement of the second lead in bilateral cases was not found to affect accuracy. The mean number of microelectrode trajectories was greater for first leads in simultaneous bilateral DBS (p = 0.032). No significant correlation between either age or target and accuracy was found. Conclusion: Although there may be other important reasons for performing DBS in a staged fashion, our study finds that neither laterality nor timing of second lead placement, patient age, or target site have significant impact on DBS lead accuracy, a finding that indicates with appropriate approach selection based on patient factors, accuracy does not have to be significantly compromised.
• Ramirez-Zamora, A., Kaszuba, B., Gee, L., Prusik, J., Danisi, F., Shin, D., & Pilitsis, J. (2016). Clinical outcome and characterization of local field potentials in holmes tremor treated with pallidal deep brain stimulation. Tremor and Other Hyperkinetic Movements, 2016. doi:10.7916/D8S182JJ
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  Background: Holmes tremor (HT) is an irregular, low-frequency rest tremor associated with prominent action and postural tremors. Currently, the most effective stereotactic target and neurophysiologic characterization of HT, specifically local field potentials (LFPs) are uncertain. We present the outcome, intraoperative neurophysiologic analysis with characterization of LFPs in a patient managed with left globus pallidus interna deep brain stimulation (Gpi DBS). Case Report: A 24-year-old male underwent left Gpi DBS for medically refractory HT. LFPs demonstrated highest powers in the delta range in Gpi. At the 6- month follow-up, a 90% reduction in tremor was observed. Discussion: Pallidal DBS should be considered as an alternative target for management of refractory HT. LFP demonstrated neuronal activity associated with higher power in the delta region, similarly seen in patients with generalized dystonia.
• Ramirez-Zamora, A., Kaszuba, B., Gee, L., Prusik, J., Molho, E., Wilock, M., Shin, D., & Pilitsis, J. (2016). Clinical outcome and intraoperative neurophysiology for focal limb dystonic tremor without generalized dystonia treated with deep brain stimulation. Clinical Neurology and Neurosurgery, 150. doi:10.1016/j.clineuro.2016.06.006
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  Objectives Dystonic tremor (DT) is defined as a postural/kinetic tremor occurring in the body region affected by dystonia. DT is typically characterized by focal tremors with irregular amplitudes and variable frequencies typically below 7 Hz. Pharmacological treatment is generally unsuccessful and guidelines for deep brain stimulation (DBS) targeting and indications are scarce. In this article, we present the outcome and neurophysiologic data of two patients with refractory, focal limb DT treated with Globus Pallidus interna (Gpi) DBS and critically review the current literature regarding surgical treatment of DT discussing stereotactic targets and treatment considerations. Patients and methods A search of literature concerning treatment of DT was conducted. Additionally, Gpi DBS was performed in two patients with DT and microelectrode recordings for multi unit analysis (MUAs) and local field potentials (LFPs) were obtained. Results The mean percentage improvement in tremor severity was 80.5% at 3 years follow up. MUAs and LFPs did not show significant differences in DT patients compared with other forms of dystonia or PD except for higher interspikes bursting indices. LFP recordings in DT demonstrated high power at low frequencies with action (
• Reid Gooch, M., & Pilitsis, J. (2016). Commentary: Percutaneous Balloon Compression vs Percutaneous Retrogasserian Glycerol Rhizotomy for the Primary Treatment of Trigeminal Neuralgia. Neurosurgery, 79(3). doi:10.1227/NEU.0000000000001343
• Rubino, S., & Pilitsis, J. (2016). Comment. Neurosurgery, 79(5). doi:10.1227/NEU.0000000000001418
• Lynch, G., Nieto, K., Puthenveettil, S., Reyes, M., Jureller, M., Huang, J., Grady, M., Harris, O., Ganju, A., Germano, I., Pilitsis, J., Pannullo, S., Benzil, D., Abosch, A., Fouke, S., & Samadani, U. (2015). Attrition rates in neurosurgery residency: Analysis of 1361 consecutive residents matched from 1990 to 1999. Journal of Neurosurgery, 122(2). doi:10.3171/2014.10.JNS132436
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  OBJECT: The objective of this study is to determine neurosurgery residency attrition rates by sex of matched applicant and by type and rank of medical school attended. METHODS: The study follows a cohort of 1361 individuals who matched into a neurosurgery residency program through the SF Match Fellowship and Residency Matching Service from 1990 to 1999. The main outcome measure was achievement of board certification as documented in the American Board of Neurological Surgery Directory of Diplomats. A secondary outcome measure was documentation of practicing medicine as verified by the American Medical Association DoctorFinder and National Provider Identifier websites. Overall, 10.7% (n = 146) of these individuals were women. Twenty percent (n = 266) graduated from a top 10 medical school (24% of women [35/146] and 19% of men [232/1215], p = 0.19). Forty-five percent (n = 618) were graduates of a public medical school, 50% (n = 680) of a private medical school, and 5% (n = 63) of an international medical school. At the end of the study, 0.2% of subjects (n = 3) were deceased and 0.3% (n = 4) were lost to follow-up. RESULTS: The total residency completion rate was 86.0% (n = 1171) overall, with 76.0% (n = 111/146) of women and 87.2% (n = 1059/1215) of men completing residency. Board certification was obtained by 79.4% (n = 1081) of all individuals matching into residency between 1990 and 1999, Overall, 63.0% (92/146) of women and 81.3% (989/1215) of men were board certified. Women were found to be significantly more at risk (p < 0.005) of not completing residency or becoming board certified than men. Public medical school alumni had significantly higher board certification rates than private and international alumni (82.2% for public [508/618]; 77.1% for private [524/680]; 77.8% for international [49/63]; p < 0.05). There was no significant difference in attrition for graduates of top 10-ranked institutions versus other institutions. There was no difference in number of years to achieve neurosurgical board certification for men versus women. CONCLUSIONS: Overall, neurosurgery training attrition rates are low. Women have had greater attrition than men during and after neurosurgery residency training. International and private medical school alumni had higher attrition than public medical school alumni.
• Prusik, J., & Pilitsis, J. (2015). Comments. Neuromodulation, 18(7). doi:10.1111/ner.12336
• Riccio, A., & Pilitsis, J. (2015). Comments. Neurosurgery, 77(5). doi:10.1227/NEU.0000000000000906
• Roth, S., Lange, S., Haller, J., De La Cruz, P., Kumar, V., Wilock, M., Paniccioli, S., Briotte, M., & Pilitsis, J. (2015). A Prospective Study of the Intra-and Postoperative Efficacy of Intraoperative Neuromonitoring in Spinal Cord Stimulation. Stereotactic and Functional Neurosurgery, 93(5). doi:10.1159/000437388
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  Background: Accurate lead placement is critical for spinal cord stimulation (SCS) efficacy. The traditional gold standard of awake placement is often technically difficult. While there is retrospective evidence supporting the use of intraoperative neurophysiological monitoring (IOM) as an alternative, a prospective assessment has not yet been performed. Objective: To prospectively evaluate pain and functionality outcomes for IOM-guided SCS, validate two IOM modalities as a means to lateralize lead placement and assess whether IOM can be useful for postoperative programming. Methods: A total of 73 patients were implanted with SCS using electromyography (EMG) and somatosensory-evoked potential collision studies (SSEP-CS) to verify lead placement. Patient pain and function were assessed through serial administration of several validated questionnaires. Stimulation parameters at 6 months were documented. Results: Statistically significant (p < 0.05) improvements were observed in the McGill Pain Questionnaire, Oswestry Disability Index, Pain Catastrophizing Scale, and Visual Analog Scale. EMG and SSEP-CS appropriately lateralized leads in 65/73 (89.0%) and 40/58 (69.0%) cases, respectively. EMG predicted active contacts in use at follow-up with 82.7% sensitivity. Conclusions: We provide prospective evidence that IOM can be used to verify SCS placement. Additionally, EMG may help to streamline device programming and thereby improve outcomes by predicting the ideal stimulation contacts in many cases.
• Boggs, H., & Pilitsis, J. (2014). Comments. Neurosurgery, 75(6). doi:10.1227/NEU.0000000000000540
• Campbell, J., & Pilitsis, J. (2014). Comments. Neurosurgery, 74(6). doi:10.1227/NEU.0000000000000321
• Pilitsis, J. (2012). Comment. Neurosurgery, 71(6). doi:10.1227/NEU.0b013e318270611f
• Pilitsis, J., Burrows, A., Linton Peters, M., Sargent, J., Ng, S., & Tseng, J. (2012). Changing practice patterns of deep brain stimulation in Parkinson's disease and essential tremor in the USA. Stereotactic and Functional Neurosurgery, 90(1). doi:10.1159/000333834
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  Background: Randomized controlled studies have shown deep brain stimulation (DBS) to be an effective treatment for Parkinson's disease (PD). Outside of large-center studies, little is known about trends in DBS use in the USA. Objectives: We employ the Nationwide Inpatient Sample to look at changes in DBS utilization over time. Methods: We identified all individuals with PD (332.0) and essential tremor (ET) (333.1) who underwent DBS (02.93) from 1998 to 2007. We examined demographics, hospital status, comorbidities, and in-hospital systemic/technical complications. DBS patients from 2000 and 2007 were compared using χ 2 tests. Results: PD patients from the 2007 sample who underwent DBS were older (p = 0.01). Both ET and PD patients had significantly more comorbidities in 2007 (p < 0.001). In-hospital complications decreased from 3.8 to 2.8%. DBS was performed in medium- or high-volume centers in 70% of cases in 2000 and in 50% in 2007. In all groups, a majority of cases (range 65-71%) underwent DBS at hospitals in the western and southern USA. Conclusions: Patients who underwent DBS in the 2007 sample were older and had more comorbidities than those in the 2000 sample; in-hospital complications remained low. Understanding trends in DBS is helpful in assessing how the technology is adopted and what relationships should be further explored. Copyright © 2011 S. Karger AG, Basel.
• Burrows, A., Smith, T., Hall, W., & Pilitsis, J. (2010). Ascending paralysis from malignant leptomeningeal melanomatosis. Journal of Neurology, Neurosurgery and Psychiatry, 81(4). doi:10.1136/jnnp.2009.183657
• Pilitsis, J., & Bakay, R. (2008). A comparative analysis of coregistered ultrasound and magnetic resonance imaging in neurosurgery: Commentary. Neurosurgery, 62(3). doi:10.1227/01.neu.0000317377.15196.45
• Pilitsis, J., & Bakay, R. (2008). Comments. Neurosurgery, 62(5). doi:10.1227/01.NEU.0000313132.04702.EA
• Pilitsis, J., & Bakay, R. (2007). Clinical problem solving: Finding the target - Commentary. Neurosurgery, 61(4). doi:10.1227/01.NEU.0000298911.78882.CA
• Ammar, K., Tubbs, R., Smyth, M., Wellons, J., Blount, J., Salter, G., Oakes, W., Pilitsis, J., Fessler, R., Saunders, R., Sonntag, V., & Benzel, E. (2003). Anatomic Landmarks for the Cervical Portion of the Thoracic Duct. Neurosurgery, 53(6). doi:10.1227/01.NEU.0000093826.31666.A5
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  OBJECTIVE: Avoidance of injury to the thoracic duct during neurosurgical procedures involving the cervical region depends on a working knowledge of its location. This study evaluates superficial anatomic landmarks for the cervical portion of the thoracic duct that may be encountered in neurosurgery of the neck. METHODS: Fifteen dissections of human cadavers were performed to study the relationship between the proximal thoracic duct and superficial landmarks (e.g., the cricoid cartilage and sternal notch of the manubrium). RESULTS: The cervical portion of the thoracic duct was found to be approximated by a roughly 4.4-cm2 region in the left supraclavicular area beginning approximately 2.0 cm lateral to the midline and 3.5 cm superior to the sternal notch, extending superiorly to a point roughly 3.5 cm from the midline and 2.5 cm inferior to the cricoid cartilage, and terminating within the venous system at a point approximately 4.5 cm lateral to the midline and 3.0 cm superior to the sternal notch. CONCLUSION: Through an increased appreciation for its location, injury to the thoracic duct may be minimized.
• Pilitsis, J., & Rengachary, S. (2001). Complications of head injury. Neurological Research, 23(2-3). doi:10.1179/016164101101198389
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  Management of head injury is based on two concepts, proper treatment of the acute insult and the prevention and treatment of secondary insults. The head injured patient is subject to both intracranial and extracranial secondary insults. This paper will review complications related to the central nervous system as well as the pulmonary, infectious, gastrointestinal, and psychiatric complications frequently seen following traumatic brain injury. Complications following head trauma lead to significant acute and chronic morbidity and mortality. It is essential that clinicians be able to recognize and treat these complications in order to more effectively manage head trauma, improve outcome, and care for patients.
• Pilitsis, J., & Kimelberg, H. (1998). Adenosine receptor mediated stimulation of intracellular calcium in acutely isolated astrocytes. Brain Research, 798(1-2). doi:10.1016/S0006-8993(98)00430-2
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  The characteristics of adenosine receptors found in glial fibrillary acid protein (GFAP)-positive astrocytes acutely isolated from the cerebral cortices of 4- to 12-day old rats were examined by evaluating the effects of adenosine and its analogues on intracellular calcium levels. First, these effects were compared with those seen in primary astrocytic cultures, and it was found that acutely isolated astrocytes showed much greater sensitivity to adenosine than their cultured counterparts. Then, the adenosine evoked calcium responses in acutely isolated cells were evaluated under various conditions. The responses to adenosine were not inhibited by papaverine, an uptake blocker, or by removal of extracellular calcium. U73122, a phospholipase C inhibitor, was able to completely inhibit the adenosine response. The receptor inhibitor 3-isobutyl-1-methylxanthine inhibited the calcium response to adenosine, providing evidence that the response is not coupled to the xanthine-insensitive A3 receptor. The stimulatory action of NECA, a non-selective analogue, was blocked neither by the A(2A)-selective receptor antagonist 8-(3-chlorostyryl) caffeine nor by the A1-selective receptor antagonist 8-cyclopentyl-1,3-dipropylxanthine. The A(2B) receptor antagonist alloxazine, however, was able to completely inhibit the increase in intracellular calcium produced by NECA. Taken together, these data suggest that the adenosine-evoked calcium response in acutely isolated astrocytes is coupled to the A(2B) receptor.