As The Johns Hopkins Hospital opened in 1889 (Fig. ), the Outpatient Department was organized und... more As The Johns Hopkins Hospital opened in 1889 (Fig. ), the Outpatient Department was organized under the direction of William S. Halsted. 1 Nine divisions were initially formed: 1) the Department of General Medicine, directed by William Osler; 2) the Department of Diseases of Children, directed by William Osler and W.D. Booker; 3) the Department of Nervous Diseases, directed by William Osler and H.M. Thomas; 4) the Department of General Surgery, directed by William S. Halsted and John M.T. Finney; 5) the Department of Genitourinary Diseases, directed by William S. Halsted and James Brown; 6) the Department of Gynecology, directed by Howard A. Kelly and Hunter Robb; 7) the Department of Ophthalmology and Otology, directed by Samuel Theobald and Robert L. Randolph; 8) the Department of Laryngology, directed by John N. Mackenzie; and 9) the Department of Dermatology, directed by R.B. Morrison. From the beginning, there was controversy about how these departments were run. Most of the physicians were private practitioners and served without any compensation for their clinical or teaching efforts. The space provided to see patients was crowded, poorly equipped, and understaffed. William S. Halsted assigned no public beds to the clinical staff; therefore, many surgical procedures were done in the clinic exam rooms, with the patients discharged after ether anesthesia. All otolaryngology cases that required the main operating rooms were referred to the general surgery staff and operated on by John M.T. Finney,
World Journal of Otorhinolaryngology - Head and Neck Surgery, 2018
Chronic rhinitis and rhinosinusitis are among the most common conditions worldwide with significa... more Chronic rhinitis and rhinosinusitis are among the most common conditions worldwide with significant morbidity and decreased quality of life. Although the pathogenesis of these conditions is multifactorial, there has been increasing evidence for the role of environmental factors such as aeroallergens and air pollutants as initiating or exacerbating factors. This review will outline the current literature focusing on the role of aeroallergens and air pollution in the pathogenesis of chronic sinonasal inflammatory conditions.
Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglott... more Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglottis, and/or trachea due to scar tissue. Patients with type 2 diabetes mellitus (T2DM) are over 8 times more likely to develop iLTS and represent 26% to 53% of all iLTS patients. In this investigation, we compared iLTS scar‐derived fibroblasts in patients with and without T2DM.
Expandable vertebral body replacement cages (VBRs) have been widely used for reconstruction of th... more Expandable vertebral body replacement cages (VBRs) have been widely used for reconstruction of the thoracolumbar spine following corpectomy. However, their use in the cervical spine is less common, and currently, no expandable cages on the market are cleared or approved by the US Food and Drug Administration for use in the cervical spine. The objective of this study was to perform a systematic review on the use of expandable cages in the treatment of cervical spine pathology with a focus on fusion rates, deformity correction, complications, and indications. A comprehensive Medline search was performed, and 24 applicable articles were identified and included in this review. The advantages of expandable cages include greater ease of implantation with less risk of damage to the end plate, less intraoperative manipulation of the device, and potentially greater control over lordosis. They may be particularly advantageous in cases with poor bone quality, such as patients with osteoporosis...
OBJECT The number of patients with spinal tumors is rapidly increasing; spinal metastases develop... more OBJECT The number of patients with spinal tumors is rapidly increasing; spinal metastases develop in more than 30% of cancer patients during the course of their illness. Such lesions can significantly decrease quality of life, often necessitating treatment. Stereotactic radiosurgery has effectively achieved local control and symptomatic relief for these patients. The authors determined prognostic factors that predicted pain palliation and report overall institutional outcomes after spine stereotactic body radiation therapy (SBRT). METHODS Records of patients who had undergone treatment with SBRT for either primary spinal tumors or spinal metastases from June 2008 through June 2013 were retrospectively reviewed. Data were collected at the initial visit just before treatment and at 1-, 3-, 6-, and 12-month follow-up visits. Collected clinical data included Karnofsky Performance Scale scores, pain status, presence of neurological deficits, and prior radiation exposure at the level of i...
The spine journal : official journal of the North American Spine Society, Jan 19, 2015
A persistent challenge in spine surgery is improving screw fixation in patients with poor bone qu... more A persistent challenge in spine surgery is improving screw fixation in patients with poor bone quality. Augmenting pedicle screw fixation with cement appears to be a promising approach. The purpose of this study was to survey the literature and assess the prior biomechanical studies on pedicle screw augmentation with cement to provide in depth discussions of the biomechanical benefits of multiple parameters in screw augmentation. A systematic literature review. A search of Medline was performed, combining search terms of pedicle screw, augmentation, vertebroplasty, kyphoplasty, PMMA, polymethylmethacrylate, calcium phosphate, or calcium sulfate. The retrieved articles were reviewed as well as their references, and articles dealing with biomechanical testing were included in this manuscript. Polymethylmethacrylate is an effective material for enhancing pedicle screw fixation in both osteoporosis and revision spine surgery models. Several other calcium ceramics also appear promising, ...
Study Design Case report. Objective The objective of the article is to illustrate a case of desmo... more Study Design Case report. Objective The objective of the article is to illustrate a case of desmoid tumor (DT) formation after posterior instrumentation of the thoracic spine. Methods A 57-year-old woman presented with lower extremity clumsiness, balance, and ambulation difficulty resulting from spinal cord compression due to an upper thoracic atypical vertebral hemangioma. Ten months after undergoing embolization, resection, and placement of instrumentation for this lesion, the patient developed a growing mass at the rostral end of the incision. Biopsy revealed desmoid fibromatosis. The mass was removed via an en bloc resection. Histology revealed an infiltrative DT above the laminectomy site abutting the instrumentation. Results At 2-year follow-up, there was no evidence of recurrence of the tumor. Conclusion Paraspinal DTs have been reported in the literature to develop after surgical procedures of the spine. Often times, patients attribute swelling or fullness at the site of their surgery to scar tissue formation or instrumentation. One must consider the possibility of a DT in the setting of reported surgical site fullness or mass after spine surgery. It is thought that postoperative inflammation present in the surgical bed may promote formation of DTs. Instrumentation may also contribute to inflammation and increase the likelihood of developing a DT. Generous margins must be taken to prevent recurrence.
Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several deca... more Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several decades. Although pedicle screws were originally placed via a free-hand technique, there has been a movement in favor of pedicle screw placement with the aid of imaging. Such assistive techniques include fluoroscopy guidance and stereotactic navigation. Imaging has the benefit of increased visualization of a pedicle's trajectory, but can result in increased morbidity associated with radiation exposure, increased time expenditure, and possible workflow interruption. Many institutions have reported high accuracies with each of these three core techniques. However, due to differing definitions of accuracy and varying radiographic analyses, it is extremely difficult to compare studies side-by-side to determine which techniques are superior. From the literature, it can be concluded that pedicles of vertebrae within the mid-thoracic spine and vertebrae that have altered morphology due to scoli...
Pain following spine surgery is often difficult to control and can persist. Reduction of this pai... more Pain following spine surgery is often difficult to control and can persist. Reduction of this pain requires a multidisciplinary approach that depends on contributions of both surgeons and anesthesiologists. The spine surgeon's role involves limiting manipulation of structures contributing to pain sensation in the spine, which requires an in-depth understanding of the specific anatomic etiologies of pain originating along the spinal axis. Anesthesiologists, on the other hand, must focus on preemptive, multimodal analgesic treatment regimens. In this review, we first discuss anatomic sources of pain within the spine, before delving into a specific literature-supported pain management protocol intended for use with spinal surgery.
A posterolateral rabbit spinal fusion model was used to evaluate the effects of recombinant human... more A posterolateral rabbit spinal fusion model was used to evaluate the effects of recombinant human bone morphogenetic protein-2 (rhBMP-2) and teriparatide (PTH [1-34]) used individually and in combination on spinal fusion outcomes. To test the efficacy of parathyroid hormone on improving spinal fusion outcomes when used with BMP-2. Of the more than 250,000 spinal fusion surgical procedures performed each year, 5% to 35% of these will result in pseudarthrosis. Growing controversy on the efficacy and cost of rhBMP-2 for improving spinal fusion outcomes has presented a challenge for clinicians. Research into PTH as an adjunct therapy to rhBMP-2 for spinal fusion has not yet been investigated. Forty-eight male New Zealand white rabbits underwent bilateral posterolateral intertransverse process arthrodesis surgery at the L5-L6 level. Animals were divided into 6 groups. Two groups were treated with autograft alone or autograft and PTH (1-34), whereas the other 4 groups were treated with low-dose rhBMP-2 alone, high-dose rhBMP-2 alone, or either dose combined with PTH (1-34). All animals were euthanized 6 weeks after surgery. The L4-L7 spinal segment was removed and assessed using manual palpation, computed tomography (CT), and biomechanical testing. CT assessments revealed fusion in 50% of autograft controls, 75% of autograft PTH (1-34) animals, 87.5% in the 2 groups treated with low-dose rhBMP-2, and 100% in the 2 groups treated with high-dose rhBMP-2. CT volumetric analysis demonstrated that all groups treated with biologics had fusion masses that were on average significantly larger than those observed in the control group (P < 0.0001). Biomechanical data demonstrated no statistical difference between controls, PTH (1-34), and low-dose rhBMP-2 in any testing orientation. PTH (1-34) did not increase bending stiffness when used adjunctively with either low-dose or high-dose rhBMP-2. Although intermittent teriparatide administration results in increased fusion mass volume, it does not improve biomechnical stiffness over use of autograft alone. When delivered concurrently with high- and low-dose rhBMP-2, teriparatide provided no statistically significant improvement in biomechanical stiffness. N/A.
Although materials for secondary cranial reconstruction have evolved with time, the overall appro... more Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant. To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance. Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura. A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal. This multidisciplinary approach illustrated in our case series, including our "pericranial-onlay" technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.
PURPOSE: The authors illustrate a case where an intercostal aneurysm was observed in a patient wi... more PURPOSE: The authors illustrate a case where an intercostal aneurysm was observed in a patient with type 1 neurofibromatosis. METHODS: A 32-year-old man with NF1 presented with thoracic back pain. The patient's symptoms progressed to include myelopathic symptoms, including difficulty urinating, numbness in the lower extremities, and increased weakness. Imaging revealed what appeared to be a neurofibroma at the T4-T5 level and a plan to resect the mass was formulated. Upon initial limited hemilaminotomy, significant arterial blood was encountered. The patient was then taken to the interventional suite and angiography was performed, revealing a left T4 intercostal aneurysm. The aneurysm was coil-embolized with no residual filling. RESULTS: By 6 months post-surgery, the patient had regained full strength and sensation in his lower extremities and no longer had difficulty urinating. There has been no recurrence of symptoms 3 years postoperatively. CONCLUSIONS: Intercostal artery lesions must be considered as a possible diagnosis in NF1.
As The Johns Hopkins Hospital opened in 1889 (Fig. ), the Outpatient Department was organized und... more As The Johns Hopkins Hospital opened in 1889 (Fig. ), the Outpatient Department was organized under the direction of William S. Halsted. 1 Nine divisions were initially formed: 1) the Department of General Medicine, directed by William Osler; 2) the Department of Diseases of Children, directed by William Osler and W.D. Booker; 3) the Department of Nervous Diseases, directed by William Osler and H.M. Thomas; 4) the Department of General Surgery, directed by William S. Halsted and John M.T. Finney; 5) the Department of Genitourinary Diseases, directed by William S. Halsted and James Brown; 6) the Department of Gynecology, directed by Howard A. Kelly and Hunter Robb; 7) the Department of Ophthalmology and Otology, directed by Samuel Theobald and Robert L. Randolph; 8) the Department of Laryngology, directed by John N. Mackenzie; and 9) the Department of Dermatology, directed by R.B. Morrison. From the beginning, there was controversy about how these departments were run. Most of the physicians were private practitioners and served without any compensation for their clinical or teaching efforts. The space provided to see patients was crowded, poorly equipped, and understaffed. William S. Halsted assigned no public beds to the clinical staff; therefore, many surgical procedures were done in the clinic exam rooms, with the patients discharged after ether anesthesia. All otolaryngology cases that required the main operating rooms were referred to the general surgery staff and operated on by John M.T. Finney,
World Journal of Otorhinolaryngology - Head and Neck Surgery, 2018
Chronic rhinitis and rhinosinusitis are among the most common conditions worldwide with significa... more Chronic rhinitis and rhinosinusitis are among the most common conditions worldwide with significant morbidity and decreased quality of life. Although the pathogenesis of these conditions is multifactorial, there has been increasing evidence for the role of environmental factors such as aeroallergens and air pollutants as initiating or exacerbating factors. This review will outline the current literature focusing on the role of aeroallergens and air pollution in the pathogenesis of chronic sinonasal inflammatory conditions.
Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglott... more Iatrogenic laryngotracheal stenosis (iLTS) is the pathological narrowing of the glottis, subglottis, and/or trachea due to scar tissue. Patients with type 2 diabetes mellitus (T2DM) are over 8 times more likely to develop iLTS and represent 26% to 53% of all iLTS patients. In this investigation, we compared iLTS scar‐derived fibroblasts in patients with and without T2DM.
Expandable vertebral body replacement cages (VBRs) have been widely used for reconstruction of th... more Expandable vertebral body replacement cages (VBRs) have been widely used for reconstruction of the thoracolumbar spine following corpectomy. However, their use in the cervical spine is less common, and currently, no expandable cages on the market are cleared or approved by the US Food and Drug Administration for use in the cervical spine. The objective of this study was to perform a systematic review on the use of expandable cages in the treatment of cervical spine pathology with a focus on fusion rates, deformity correction, complications, and indications. A comprehensive Medline search was performed, and 24 applicable articles were identified and included in this review. The advantages of expandable cages include greater ease of implantation with less risk of damage to the end plate, less intraoperative manipulation of the device, and potentially greater control over lordosis. They may be particularly advantageous in cases with poor bone quality, such as patients with osteoporosis...
OBJECT The number of patients with spinal tumors is rapidly increasing; spinal metastases develop... more OBJECT The number of patients with spinal tumors is rapidly increasing; spinal metastases develop in more than 30% of cancer patients during the course of their illness. Such lesions can significantly decrease quality of life, often necessitating treatment. Stereotactic radiosurgery has effectively achieved local control and symptomatic relief for these patients. The authors determined prognostic factors that predicted pain palliation and report overall institutional outcomes after spine stereotactic body radiation therapy (SBRT). METHODS Records of patients who had undergone treatment with SBRT for either primary spinal tumors or spinal metastases from June 2008 through June 2013 were retrospectively reviewed. Data were collected at the initial visit just before treatment and at 1-, 3-, 6-, and 12-month follow-up visits. Collected clinical data included Karnofsky Performance Scale scores, pain status, presence of neurological deficits, and prior radiation exposure at the level of i...
The spine journal : official journal of the North American Spine Society, Jan 19, 2015
A persistent challenge in spine surgery is improving screw fixation in patients with poor bone qu... more A persistent challenge in spine surgery is improving screw fixation in patients with poor bone quality. Augmenting pedicle screw fixation with cement appears to be a promising approach. The purpose of this study was to survey the literature and assess the prior biomechanical studies on pedicle screw augmentation with cement to provide in depth discussions of the biomechanical benefits of multiple parameters in screw augmentation. A systematic literature review. A search of Medline was performed, combining search terms of pedicle screw, augmentation, vertebroplasty, kyphoplasty, PMMA, polymethylmethacrylate, calcium phosphate, or calcium sulfate. The retrieved articles were reviewed as well as their references, and articles dealing with biomechanical testing were included in this manuscript. Polymethylmethacrylate is an effective material for enhancing pedicle screw fixation in both osteoporosis and revision spine surgery models. Several other calcium ceramics also appear promising, ...
Study Design Case report. Objective The objective of the article is to illustrate a case of desmo... more Study Design Case report. Objective The objective of the article is to illustrate a case of desmoid tumor (DT) formation after posterior instrumentation of the thoracic spine. Methods A 57-year-old woman presented with lower extremity clumsiness, balance, and ambulation difficulty resulting from spinal cord compression due to an upper thoracic atypical vertebral hemangioma. Ten months after undergoing embolization, resection, and placement of instrumentation for this lesion, the patient developed a growing mass at the rostral end of the incision. Biopsy revealed desmoid fibromatosis. The mass was removed via an en bloc resection. Histology revealed an infiltrative DT above the laminectomy site abutting the instrumentation. Results At 2-year follow-up, there was no evidence of recurrence of the tumor. Conclusion Paraspinal DTs have been reported in the literature to develop after surgical procedures of the spine. Often times, patients attribute swelling or fullness at the site of their surgery to scar tissue formation or instrumentation. One must consider the possibility of a DT in the setting of reported surgical site fullness or mass after spine surgery. It is thought that postoperative inflammation present in the surgical bed may promote formation of DTs. Instrumentation may also contribute to inflammation and increase the likelihood of developing a DT. Generous margins must be taken to prevent recurrence.
Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several deca... more Pedicle screw instrumentation has been used to stabilize the thoracolumbar spine for several decades. Although pedicle screws were originally placed via a free-hand technique, there has been a movement in favor of pedicle screw placement with the aid of imaging. Such assistive techniques include fluoroscopy guidance and stereotactic navigation. Imaging has the benefit of increased visualization of a pedicle's trajectory, but can result in increased morbidity associated with radiation exposure, increased time expenditure, and possible workflow interruption. Many institutions have reported high accuracies with each of these three core techniques. However, due to differing definitions of accuracy and varying radiographic analyses, it is extremely difficult to compare studies side-by-side to determine which techniques are superior. From the literature, it can be concluded that pedicles of vertebrae within the mid-thoracic spine and vertebrae that have altered morphology due to scoli...
Pain following spine surgery is often difficult to control and can persist. Reduction of this pai... more Pain following spine surgery is often difficult to control and can persist. Reduction of this pain requires a multidisciplinary approach that depends on contributions of both surgeons and anesthesiologists. The spine surgeon's role involves limiting manipulation of structures contributing to pain sensation in the spine, which requires an in-depth understanding of the specific anatomic etiologies of pain originating along the spinal axis. Anesthesiologists, on the other hand, must focus on preemptive, multimodal analgesic treatment regimens. In this review, we first discuss anatomic sources of pain within the spine, before delving into a specific literature-supported pain management protocol intended for use with spinal surgery.
A posterolateral rabbit spinal fusion model was used to evaluate the effects of recombinant human... more A posterolateral rabbit spinal fusion model was used to evaluate the effects of recombinant human bone morphogenetic protein-2 (rhBMP-2) and teriparatide (PTH [1-34]) used individually and in combination on spinal fusion outcomes. To test the efficacy of parathyroid hormone on improving spinal fusion outcomes when used with BMP-2. Of the more than 250,000 spinal fusion surgical procedures performed each year, 5% to 35% of these will result in pseudarthrosis. Growing controversy on the efficacy and cost of rhBMP-2 for improving spinal fusion outcomes has presented a challenge for clinicians. Research into PTH as an adjunct therapy to rhBMP-2 for spinal fusion has not yet been investigated. Forty-eight male New Zealand white rabbits underwent bilateral posterolateral intertransverse process arthrodesis surgery at the L5-L6 level. Animals were divided into 6 groups. Two groups were treated with autograft alone or autograft and PTH (1-34), whereas the other 4 groups were treated with low-dose rhBMP-2 alone, high-dose rhBMP-2 alone, or either dose combined with PTH (1-34). All animals were euthanized 6 weeks after surgery. The L4-L7 spinal segment was removed and assessed using manual palpation, computed tomography (CT), and biomechanical testing. CT assessments revealed fusion in 50% of autograft controls, 75% of autograft PTH (1-34) animals, 87.5% in the 2 groups treated with low-dose rhBMP-2, and 100% in the 2 groups treated with high-dose rhBMP-2. CT volumetric analysis demonstrated that all groups treated with biologics had fusion masses that were on average significantly larger than those observed in the control group (P < 0.0001). Biomechanical data demonstrated no statistical difference between controls, PTH (1-34), and low-dose rhBMP-2 in any testing orientation. PTH (1-34) did not increase bending stiffness when used adjunctively with either low-dose or high-dose rhBMP-2. Although intermittent teriparatide administration results in increased fusion mass volume, it does not improve biomechnical stiffness over use of autograft alone. When delivered concurrently with high- and low-dose rhBMP-2, teriparatide provided no statistically significant improvement in biomechanical stiffness. N/A.
Although materials for secondary cranial reconstruction have evolved with time, the overall appro... more Although materials for secondary cranial reconstruction have evolved with time, the overall approach in terms of bone flap/implant reconstruction after necessary delay has remained constant. To present our cases series of 50 consecutive secondary cranial reconstruction patients and to describe a multidisciplinary cranioplasty approach developed to reduce morbidity, to minimize infection, and to improve aesthetic appearance. Standard technique teaches us to place the bone flap and/or alloplastic implant directly over the dura or dural protectant after scalp flap re-elevation. However, this procedure is fraught with high complication rates, including infection. While raising the previously incised scalp flap overlying the full-thickness calvarial defect, the dissection is performed within the loose areolar tissue plane beneath the galea aponeurosis, thus leaving vascularized pericranium intact over the dura. A total of 50 consecutive patients were treated by the senior author encompassing 46 cranioplasties using the pericranial-onlay approach, along with 4 isolated temporal soft tissue reconstructions with liquid poly-methyl-methacrylate. Of the 46 cranioplasties (> 5 cm), only 1 autologous bone flap developed deep infection necessitating bone flap removal (1 of 46, 2.17%; 95% confidence interval, 0.003-11.3). None of the alloplastic custom implants placed have developed any infection requiring removal. This multidisciplinary approach illustrated in our case series, including our "pericranial-onlay" technique described here for the first time, has the potential to improve patient outcomes, to decrease perioperative morbidity, and to minimize costs associated with postoperative infections after secondary cranial reconstruction.
PURPOSE: The authors illustrate a case where an intercostal aneurysm was observed in a patient wi... more PURPOSE: The authors illustrate a case where an intercostal aneurysm was observed in a patient with type 1 neurofibromatosis. METHODS: A 32-year-old man with NF1 presented with thoracic back pain. The patient's symptoms progressed to include myelopathic symptoms, including difficulty urinating, numbness in the lower extremities, and increased weakness. Imaging revealed what appeared to be a neurofibroma at the T4-T5 level and a plan to resect the mass was formulated. Upon initial limited hemilaminotomy, significant arterial blood was encountered. The patient was then taken to the interventional suite and angiography was performed, revealing a left T4 intercostal aneurysm. The aneurysm was coil-embolized with no residual filling. RESULTS: By 6 months post-surgery, the patient had regained full strength and sensation in his lower extremities and no longer had difficulty urinating. There has been no recurrence of symptoms 3 years postoperatively. CONCLUSIONS: Intercostal artery lesions must be considered as a possible diagnosis in NF1.
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Papers by Ioan Lina