IU Indianapolis ScholarWorks :: Browsing by Author "Raskin, Jeffrey S."

Browsing by Author "Raskin, Jeffrey S."

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Application of Lean Principles to Neurosurgical Procedures: The Case of Lumbar Spinal Fusion Surgery, a Literature Review and Pilot Series
(Oxford, 2018) Liu, Jesse J.; Raskin, Jeffrey S.; Hardaway, Fran; Holste, Katherine; Brown, Sarah; Raslan, Ahmed M.; Neurological Surgery, School of Medicine
BACKGROUND Delivery of higher value healthcare is an ultimate government and public goal. Improving efficiency by standardization of surgical steps can improve patient outcomes, reduce costs, and lead to higher value healthcare. Lean principles and methodology have improved timeliness in perioperative medicine; however, process mapping of surgery itself has not been performed. OBJECTIVE To apply Plan/Do/Study/Act (PDSA) cycles methodology to lumbar posterior instrumented fusion (PIF) using lean principles to create a standard work flow, identify waste, remove intraoperative variability, and examine feasibility among pilot cases. METHODS Process maps for 5 PIF procedures were created by a PDSA cycle from 1 faculty neurosurgeon at 1 institution. Plan, modularize PIF into basic components; Do, map and time components; Study, analyze results; and Act, identify waste. Waste inventories, spaghetti diagrams, and chartings of time spent per step were created. Procedural steps were broadly defined in order to compare steps despite the variability in PIF and were analyzed with box and whisker plots to evaluate variability. RESULTS Temporal variabilities in duration of decompression vs closure and hardware vs closure were significantly different (P = .003). Variability in procedural step duration was smallest for closure and largest for exposure. Wastes including waiting and instrument defects accounted for 15% and 66% of all waste, respectively. CONCLUSION This pilot series demonstrates that lean principles can standardize surgical workflows and identify waste. Though time and labor intensive, lean principles and PDSA methodology can be applied to operative steps, not just the perioperative period.
Concomitant brain abscess and spinal cord abscess in an immunocompetent teenage male: illustrative case
(American Association of Neurological Surgeons, 2023-01-23) Virtanen, Piiamaria S.; Jimenez, Med Jimson D.; Horak, V. Jane; Desai, Virendra R.; Manaloor, John J.; Raskin, Jeffrey S.; Neurological Surgery, School of Medicine
Background: Multiple bilateral brain abscesses occur rarely in immunocompetent patients. Hematogenous spread to the central nervous system (CNS) allows suppuration and abscess formation in the privileged immune environment of the CNS; hematogenous spread to the spinal cord is extremely rare and the combination of multifocal brain abscesses and intramedullary abscesses has not been reported. This report presents a rare presentation and diagrams a treatment algorithm involving iterative minimal access surgeries and prolonged medical management. Observations: The authors present a case of an 18-year-old male with numerous multifocal and bilateral intraparenchymal abscesses and a medically resistant C5 intramedullary spinal cord abscess. The symptomatic patient had a left oculomotor palsy and left hemiparesis, ultimately undergoing ultrasound-guided aspiration of abscesses in the left frontal and left cerebral peduncle. Following transient motor improvement, he evolved tetraparesis prompting spinal cord imaging and emergent ultrasound-guided needle aspiration of an occult C5 intramedullary spinal cord abscess. The patient received appropriate medical therapy, completed inpatient rehabilitation, and made a full recovery. Lessons: Needle- and ultrasound-guided catheter drainage of CNS abscesses should be considered for symptomatic lesions. Following the neurological examination closely is extremely important; if the expected neurological improvement is delayed or regresses, then expanded imaging is warranted.
Giant Actinomyces brain abscess in an immunocompetent child: A management strategy
(Scientific Scholar, 2021-07-06) Chicoine, Nicole H.; Griffith-Linsley, Jackson; Goh, Joling; Manaloor, John J.; Raskin, Jeffrey S.; Neurological Surgery, School of Medicine
Background: Intraparenchymal brain abscess is a collection of microbes caused by inoculation through direct extension or hematogenous spread. Although rare, intraparenchymal abscesses are potentially fatal and can be detected when patients are symptomatic due to local mass effect on adjacent neural tissue. Brain abscess treatment includes medical management with appropriate antibiotics alone or medical management in combination with surgical debridement. Treatment strategies depend on the size and location of disease, as well as the virulence of the microorganism. Similar to medical management strategies, surgical strategies among providers are not uniform, with variation in approaches from complete extirpation of the abscess, including the abscess wall, to minimally invasive stereotactic needle aspiration. In particular, for children, there are no guidelines for therapy. Case description: We report a case of giant Actinomycosis right frontal brain abscess in an immunocompetent child without risk factors. A review of the literature for the treatment of brain abscess caused very rarely by Actinomyces in children is performed. Conclusion: Successful treatment of brain access depends on organism and location. The even more uncommon giant intraparenchymal abscesses can be managed with minimal access and prolonged antibiosis, especially when slow-growing organisms are identified. Long-term follow-up should be employed to mitigate missed late failures.
Iatrogenic Spinal Deformity Following Spinal Intradural Arachnoid Cyst Fenestration Despite Minimal Access With Laminoplasty and Endoscopy in a Pediatric Patient
(Cureus, 2022-02-09) Ordaz, Josue D.; Huh, Andrew; Desai, Virendra; Raskin, Jeffrey S.; Neurological Surgery, School of Medicine
Spinal intradural arachnoid cysts (SAC) are non-neoplastic lesions that can cause spinal cord compression and present with myelopathy, radiculopathy, and/or back pain. Because these cysts typically span multiple levels, endoscopy could be a useful tool to avoid wide exposure. We present an 8-year-old patient with a history of gait imbalance and urinary incontinence who was found to have a SAC spanning C7 to T6 causing spinal cord compression. An osteoplastic laminoplasty was performed from T4 to T7 followed by ultrasonic verification of intracystic septations, dural opening, and cyst fenestration. A flexible endoscope was then introduced into the cystic cavity to guide complete rostral and caudal decompression of the arachnoid cyst. At six months follow-up, the patient was able to ambulate independently, but his urinary incontinence remained unchanged. Despite the combination of ultrasound and neuroendoscopy to minimize exposure, our patient suffered from worsening kyphosis from 36 degrees preoperative to 55 degrees postoperative and worsening scoliosis from 17 to 39 degrees which required treatment with a thoracolumbar sacral orthosis. Preoperative imaging demonstrated a reverse S-shaped scoliosis with the apex at T6 and T7 which were the levels included in the laminoplasty. This illustrates the need for careful preoperative risk stratification to avoid this postoperative complication.
Intracranial arachnoid cysts: Pediatric neurosurgery update
(Scientific Scholar, 2019-02-06) Jafrani, Ryan; Raskin, Jeffrey S.; Kaufman, Ascher; Lam, Sandi; Neurological Surgery, School of Medicine
Background: With the greater worldwide availability of neuroimaging, more intracranial arachnoid cysts (IACs) are being found in all age groups. A subset of these lesions become symptomatic and requires neurosurgical management. The clinical presentations of IACs vary from asymptomatic to extremely symptomatic. Here, we reviewed the clinical presentation and treatment considerations for pediatric IACs. Case Description: Here, we presented three cases of IAC, focusing on different clinical and treatment considerations. Conclusion: IACs can be challenging to manage. There is no Class I Evidence to guide how these should be treated. We suggest clinical decision-making framework as to how to treat IACs based on our understanding of the natural history, risks/benefits of treatments, and outcomes in the future, require better patient selection for the surgical management of IACs will be warranted.
Measures of Health-Related Quality of Life Outcomes in Pediatric Neurosurgery: Literature Review
(Elsevier, 2019-02) Desai, Virendra R.; Gadgil, Nisha; Saad, Shahbaz; Raskin, Jeffrey S.; Lam, Sandi K.; Neurological Surgery, School of Medicine
Background Improving value in healthcare means optimizing outcomes and minimizing costs. The emerging pay-for-performance era requires understanding of the effect of healthcare services on health-related quality of life (HRQoL). Pediatric and surgical subspecialties have yet to fully integrate HRQoL measures into practice. The present study reviewed and characterized the HRQoL outcome measures across various pediatric neurosurgical diagnoses. Methods A literature review was performed by searching PubMed and Google Scholar with search terms such as “health-related quality of life” and “pediatric neurosurgery” and then including the specific pathologies for which a HRQoL instrument was found (e.g., “health-related quality of life” plus “epilepsy”). Each measurement was evaluated by content and purpose, relative strengths and weaknesses, and validity. Results We reviewed 68 reports. Epilepsy, brain tumor, cerebral palsy, spina bifida, hydrocephalus, and scoliosis were diagnoses found in reported studies that had used disease-specific HRQoL instruments. Information using general HRQoL instruments was also reported. Internal, test–retest, and/or interrater reliability varied across the instruments, as did face, content, concurrent, and/or construct validity. Few instruments were tested enough for robust reliability and validity. Significant variability was found in the usage of these instruments in clinical studies within pediatric neurosurgery. Conclusions The HRQoL instruments used in pediatric neurosurgery are currently without standardized guidelines and thus exhibit high variability in use. Clinicians should support the development and application of these methods to optimize these instruments, promote standardization of research, improve performance measures to reflect clinically modifiable and meaningful outcomes, and, ultimately, lead the national discussion in healthcare quality and patient-centered care.
Network-Targeted Approach and Postoperative Resting-State Functional Magnetic Resonance Imaging Are Associated with Seizure Outcome
(Wiley, 2019-09) Boerwinkle, Varina L.; Cediel, Emilio G.; Mirea, Lucia; Williams, Korwyn; Kerrigan, John F.; Lam, Sandi; Raskin, Jeffrey S.; Desai, Virendra R.; Wilfong, Angus A.; Adelson, P. David; Curry, Daniel J.; Surgery, School of Medicine
Objective Postoperative resting‐state functional magnetic resonance imaging (MRI) in children with intractable epilepsy has not been quantified in relation to seizure outcome. Therefore, its value as a biomarker for epileptogenic pathology is not well understood. Methods In a sample of children with intractable epilepsy who underwent prospective resting‐state seizure onset zone (SOZ)‐targeted epilepsy surgery, postoperative resting‐state functional MRI (rs‐fMRI) was performed 6 to 12 months later. Graded normalization of the postoperative resting‐state SOZ was compared to seizure outcomes, patient, surgery, and anatomical MRI characteristics. Results A total of 64 cases were evaluated. Network‐targeted surgery, followed by postoperative rs‐fMRI normalization was significantly (p < 0.001) correlated with seizure reduction, with a Spearman rank correlation coefficient of 0.83. Of 39 cases with postoperative rs‐fMRI SOZ normalization, 38 (97%) became completely seizure free. In contrast, of the 25 cases without complete rs‐fMRI SOZ normalization, only 3 (5%) became seizure free. The accuracy of rs‐fMRI as a biomarker predicting seizure freedom is 94%, with 96% sensitivity and 93% specificity. Interpretation Among seizure localization techniques in pediatric epilepsy, network‐targeted surgery, followed by postoperative rs‐fMRI normalization, has high correlation with seizure freedom. This study shows that rs‐fMRI SOZ can be used as a biomarker of the epileptogenic zone, and postoperative rs‐fMRI normalization is a biomarker for SOZ quiescence.
Rapid Improvement Project: Improving Caregivers’ Understanding of Safety Recommendations for Neurosurgical Devices
(Wolters Kluwer, 2020-12-28) Anokwute, Miracle C.; Seibold, Dianne; Jea, Andrew; Ackerman, Laurie L.; Raskin, Jeffrey S.; Neurological Surgery, School of Medicine
There has been a proliferation in the development of indwelling neuromodulatory devices with varied safety recommendations, making it difficult for providers to remain up-to-date. This deficit presents an opportunity for significant improvement in patient safety. Methods: We performed a search for monopolar electrocautery and magnetic resonance imaging safety recommendations for several indwelling neuromodulatory devices. We developed a questionnaire followed by an educational compendium and a posttest for 50 care providers. Results: Overall, there was a poor performance on the pretest (mean 39%, SD 19%) but significant improvement on the posttest (mean 71%, SD 16%), P < 0.0001. We placed the educational compendium that included all manufacturer recommendations in the operating room for easy reference. A 2.4 times decrease in the case start times of vagus nerve stimulator cases is evidence of its effectiveness. Conclusions: The authors highlight the lack of knowledge about manufacturer safety recommendations for indwelling neurosurgical devices, which led to the creation of operating room supplements and educational devices.
Standard work tools for dynamic stereoelectroencephalography using ROSA: naming convention and perioperative planning
(JNS, 2021-04) Bakr, Salma M.; Patel, Ajay; Zaazoue, Mohamed A.; Wagner, Kathryn; Lam, Sandi K.; Curry, Daniel J.; Raskin, Jeffrey S.; Neurological Surgery, School of Medicine
OBJECTIVE The grid-based orthogonal placement of depth electrodes (DEs), initially defined by Jean Talairach and Jean Bancaud, is known as stereo-electroencephalography (sEEG). Although acceptance in the United States was initially slow, advances in imaging and technology have spawned a proliferation of North American epilepsy centers offering sEEG. Despite publications highlighting minimal access techniques and varied indications, standard work for phase I targeted DE has not been defined. In this article, the authors propose the term “dynamic sEEG” and define standard work tools and related common data elements to promote uniformity in the field. METHODS A multidisciplinary approach from July to August 2016 resulted in the production of 4 standard work tools for dynamic sEEG using ROSA: 1) a 34-page illustrated manual depicting a detailed workflow; 2) a planning form to collocate all the phase I data; 3) a naming convention for DEs that encodes the data defining it; and 4) a reusable portable perioperative planning and documentation board. A retrospective review of sEEG case efficiency was performed comparing those using standard work tools (between July 2016 and April 2017) with historical controls (between March 2015 and June 2016). The standard work tools were then instituted at another epilepsy surgery center, and the results were recorded. RESULTS The process for dynamic sEEG was formally reviewed, including anesthesia, positioning, perioperative nursing guidelines, surgical steps, and postoperative care for the workflow using cranial fixation and ROSA-guided placement. There was a 40% improvement in time per electrode, from 44.7 ± 9.0 minutes to 26.9 ± 6.5 minutes (p = 0.0007) following the development and use of the manual, the naming convention, and the reusable portable perioperative planning and documentation board. This standardized protocol was implemented at another institution and yielded a time per electrode of 22.3 ± 4.4 minutes. CONCLUSIONS The authors propose the term dynamic sEEG for stereotactic depth electrodes placed according to phase I workup data with the intention of converting to ablation. This workflow efficiency can be optimized using the standard work tools presented. The authors also propose a novel naming convention that encodes critical data and allows portability among providers. Use of a planning form for common data elements optimizes research, and global adoption could facilitate multicenter studies correlating phase I modality and seizure onset zone identification.
Surgical Management of Trigeminal Neuralgia in Children
(Elsevier, 2019-01) Chicoine, Nicole H.; Yaacoub, Alan P.; Jea, Andrew; Raskin, Jeffrey S.; Neurological Surgery, School of Medicine
Background Trigeminal neuralgia (TN) is a well-recognized facial pain syndrome. Discrete forms with disparate pain symptoms include classic and atypical. However, atypical facial pain includes neuralgiform pain along a spectrum. Most cases of TN are diagnosed in the adult population. Case reports and series of children have presented TN as a similar entity, with treatment similar to that for adults. We reviewed the pertinent data and present 2 pediatric TN cases successfully treated with microvascular decompression (MVD). Case Description Two pediatric patients (age 12 and 15 years) with TN refractory to previous medical therapy were identified. Both patients were deemed appropriate surgical candidates and underwent MVD to manage their TN. TN compression was arterial in both cases and involved portions of the anterior inferior cerebellar artery. Patient 1 was pain free 6 months after the procedure. Patient 2 was pain free immediately after the procedure and had been weaned off preoperative symptomatic management at the latest follow-up visit. The most recent follow-up examination was 12 and 8 months for patients 1 and 2, respectively, with both experiencing continued freedom from pain. Conclusions Few studies have reported on the effectiveness of MVD in the pediatric population for the management of TN. The supporting data and our 2 cases have demonstrated that MVD is effective for pediatric patients to treat their TN. Furthermore, the side effects appear to be minimal, with excellent pain relief after MVD in this patient population.

Browsing by Author "Raskin, Jeffrey S."

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