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Computed tomography parameters for atlantooccipital dislocation in adult patients: the occipital condyle-C1 interval. - Journal of neurosurgery. Spine
OBJECT Atlantooccipital dislocation (AOD) in adults cannot be diagnosed with adequate specificity and sensitivity using only CT or plain radiography, and the spine literature offers no guidelines. In children, the most sensitive and specific radiographic measurement for the diagnosis of AOD is the CT-based occipital condyle-C1 interval (CCI). The goal of the current study was to identify the normal CCI in healthy adults and compare it with the CCI in adults with AOD to establish a highly sensitive and specific cutoff value for the neuroimaging diagnosis of AOD. METHODS A total of 81 patients, 59 without AOD and 22 with AOD, were included in this study. Measurements obtained from thin-slice CT scans of the craniovertebral joint to assess atlantooccipital dislocation included the CCI, condylar sum, the Wholey and Harris intervals, Powers and Sun ratios, Wackenheim line, and Lee X-lines. RESULTS The group of patients without AOD included 30 men (50.8%) and 29 women (49.2%) with a mean age of 42.4 Â± 16 years (range 19-87 years). The group of patients with AOD included 10 men (45.5%) and 12 women (54.5%) with a mean age of 38.2 Â± 9.7 years (range 20-56 years). Interrater reliabilities within a 95% CI were all greater than 0.98 for CCI measurements. A total of 1296 measurements of the CCI were made in 81 patients. The mean CCI for non-AOD patients was 0.89 Â± 0.12 mm, the single largest CCI measurement was 1.4 mm, and the largest mean for either right or left CCI was 1.2 mm. The mean condylar sum was 1.8 Â± 0.2 mm, and the largest condylar sum value was 2.2 mm. Linear regression with age predicted an increase in CCI of 0.001 mm/year (p < 0.05). The mean CCI in AOD patients was 3.35 Â± 0.18 mm (range 1.5 mm-6.4 mm). The shortest single CCI measurements in the AOD patients were 1.1 mm and 1.2 mm. The mean condylar sum for all 22 AOD patients was 6.7 Â± 2.7 mm and the shortest condylar sums were 3.0 mm. Cutoff values for AOD were set at 1.5 mm for the CCI and 3.0 mm for the condylar sum, both with a sensitivity of 1 and false-negative rate of 0. Sensitivity for the Powers, Wholey, Harris, Sun, Wackenheim, and Lee criteria were determined to be 0.55, 0.46, 0.27, 0.23, 0.41, and 0.41, respectively. CONCLUSIONS The CCI is shorter in adult patients as opposed to the pediatric population. The revised CCI (1.5 mm) and condylar sum (3.0 mm) cutoff values have the highest sensitivity and specificity for the diagnosis of AOD in the adult population.
The role of obesity in the biomechanics and radiological changes of the spine: an in vitro study. - Journal of neurosurgery. Spine
OBJECT The effects of obesity on lumbar biomechanics are not fully understood. The aims of this study were to analyze the biomechanical differences between cadaveric L4-5 lumbar spine segments from a large group of nonobese (body mass index [BMI] < 30 kg/m(2)) and obese (BMI â‰¥ 30 kg/m(2)) donors and to determine if there were any radiological differences between spines from nonobese and obese donors using MR imaging. METHODS A total of 168 intact L4-5 spinal segments (87 males and 81 females) were tested using pure-moment loading, simulating flexion-extension, lateral bending, and axial rotation. Axial compression tests were performed on 38 of the specimens. Sex, age, and BMI were analyzed with biomechanical parameters using 1-way ANOVA, Pearson correlation, and multiple regression analyses. MR images were obtained in 12 specimens (8 from obese and 4 from nonobese donors) using a 3-T MR scanner. RESULTS The segments from the obese male group allowed significantly greater range of motion (ROM) than those from the nonobese male group during axial rotation (p = 0.018), while there was no difference between segments from obese and nonobese females (p = 0.687). There were no differences in ROM between spines from obese and nonobese donors during flexion-extension or lateral bending for either sex. In the nonobese population, the ROM during axial rotation was significantly greater for females than for males (p = 0.009). There was no significant difference between sexes in the obese population (p = 0.892). Axial compressive stiffness was significantly greater for the obese than the nonobese population for both the female-only group and the entire study group (p < 0.01); however, the difference was nonsignificant in the male population (p = 0.304). Correlation analysis confirmed a significant negative correlation between BMI and resistance to deformation during axial compression in the female group (R = -0.65, p = 0.004), with no relationship in the male group (R = 0.03, p = 0.9). There was also a significant negative correlation between ROM during flexion-extension and BMI for the female group (R = -0.38, p = 0.001), with no relationship for the male group (R = 0.06, p = 0.58). Qualitative analysis using MR imaging indicated greater facet degeneration and a greater incidence of disc herniations in the obese group than in the control group. CONCLUSIONS Based on flexibility and compression tests, lumbar spinal segments from obese versus nonobese donors seem to behave differently, biomechanically, during axial rotation and compression. The differences are more pronounced in women. MR imaging suggests that these differences may be due to greater facet degeneration and an increased amount of disc herniation in the spines from obese individuals.
Surgical Management of a Patient With Thoracic Spinal Cord Herniation: Case Report. - Neurosurgery
Thoracic spinal cord herniation (TSCH) is rare and likely underdiagnosed. It is characterized by ventral herniation of the spinal cord through a dural defect, effacement of the anterior subarachnoid space, and increased posterior subarachnoid space. We present here a case of TSCH diagnosed and surgically treated at Barrow Neurological Institute, along with supplemental intraoperative video.A 61-year-old man with a history of progressive myelopathy causing left lower-extremity weakness with associated numbness, impaired gait, foot drop, incontinence, and sexual impotence was referred without any previous treatment. Computed tomographic myelography and magnetic resonance imaging of the thoracic spine showed ventral spinal cord herniation at T3-T4. Neurological monitoring was recorded preoperatively and intraoperatively. The patient underwent left-sided posterolateral exploration via T3-T4 laminectomies and costotransversectomy for intradural cord release/detethering of the spinal cord with additional superior and inferior extension and repair of the dural defect. Arthrodesis was not considered necessary. After cord release, motor evoked potentials showed immediate improvement from baseline. Dural duplication was considered the cause of TSCH in this case. Total reduction of herniation was evident in postoperative images. The postoperative course was uneventful, and at the last follow-up, the patient had regained ambulation and sphincter control.Anterior displacement of the thoracic spinal cord should elicit consideration of herniation to prevent misdiagnosis and inadequate surgery. Surgical cord release and enlargement of the dural defect are safe and associated with good clinical outcomes.
Persistent Outpatient Hypertension Is Independently Associated with Spinal Cord Dysfunction and Imaging Characteristics of Spinal Cord Damage among Patients with Cervical Spondylosis. - World neurosurgery
Hypertension and cervical spondylosis are diseases of the adult population that are approaching near pandemic proportions. However, the interactions between these two disease processes are poorly understood. We set out to determine the associations among systemic hypertension, clinical status, and imaging findings of spinal cord damage for patients with cervical stenosis.A retrospective chart review was performed on patients with symptomatic cervical stenosis related to degenerative disease and divided on the basis of outpatient blood pressure control (normal <140/<90 mm Hg). Sagittal T2-weighted magnetic resonance imaging (MRI) of the cervical spine was analyzed to determine the degree of maximal canal stenosis (MCS; %), surface area of increased signal intensity (ISI; cm(2)), and signal intensity ratio (SIR). Functional status was evaluated using the modified Japanese Orthopaedic Association (mJOA) scale and the Nurick scale.One hundred twenty-two patients were identified (64 hypertensive, 58 nonhypertensive). Likelihood of ISI was higher in hypertensive patients (P < 0.05). Average ISI was significantly higher in patients with uncontrolled blood pressure (P = 0.02) despite MCS being identical between the two groups. The mJOA and Nurick scores were worse for patients with systemic hypertension (PÂ <Â 0.02). Diabetes mellitus and smoking history did not affect these findings.Persistent hypertension in outpatients is associated with worsened clinical status and increased markers of spinal cord damage on MRI. Perioperative management of blood pressure may serve to improve clinical outcomes. Larger prospective trials are necessary to further validate these findings.Copyright Â© 2015 Elsevier Inc. All rights reserved.
Endoscopic endonasal atlantoaxial transarticular screw fixation technique: an anatomical feasibility and biomechanical study. - Journal of neurosurgery. Spine
OBJECT The primary disadvantage of the posterior cervical approach for atlantoaxial stabilization after odontoidectomy is that it is conducted as a second-stage procedure. The goal of the current study is to assess the surgical feasibility and biomechanical performance of an endoscopic endonasal surgical technique for C1-2 fixation that may eliminate the need for posterior fixation after odontoidectomy. METHODS The first step of the study was to perform endoscopic endonasal anatomical dissections of the craniovertebral junction in 10 silicone-injected fixed cadaveric heads to identify relevant anatomical landmarks. The second step was to perform a quantitative analysis using customized software in 10 reconstructed adult cervical spine CT scans to identify the optimal screw entry point and trajectory. The third step was biomechanical flexibility testing of the construct and comparison with the posterior C1-2 transarticular fixation in 14 human cadaveric specimens. RESULTS Adequate surgical exposure and identification of the key anatomical landmarks, such as C1-2 lateral masses, the C-1 anterior arch, and the odontoid process, were provided by the endonasal endoscopic approach in all specimens. Radiological analysis of anatomical detail suggested that the optimal screw entry point was on the anterior aspect of the C-1 lateral mass near the midpoint, and the screw trajectory was inferiorly and slightly laterally directed. The custommade angled instrumentation was crucial for screw placement. Biomechanical analysis suggested that anterior C1-2 fixation compared favorably to posterior fixation by limiting flexion-extension, axial rotation, and lateral bending (p > 0.3). CONCLUSIONS This is the first study that demonstrates the feasibility of an endoscopic endonasal technique for C1-2 fusion. This novel technique may have clinical utility by eliminating the need for a second-stage posterior fixation operation in certain patients undergoing odontoidectomy.
Quantitative study of the opticocarotid and carotid-oculomotor windows for the interpeduncular fossa, before and after internal carotid artery mobilization and posterior communicating division. - Neurosurgery
The management of basilar apex (BX) aneurysms remains problematic.We quantified the surgical exposure of the BX through the opticocarotid window (OCW) and the carotid-oculomotor window (COW), before and after mobilization of the internal carotid artery and division of the posterior communicating artery (PCoA).Eleven silicone-injected cadaveric heads were dissected bilaterally. The surgical dissection was divided into 4 major steps: (1) supraorbital modified orbitozygomatic craniotomy, (2) mobilization of the internal carotid artery after drilling out the anterior clinoid process intradurally and cutting the distal dural ring, (3) drilling out the posterior clinoid process and dorsum sellae, and (4) dividing the PCoA from the posterior third portion of the vessel. A frameless navigation system was used to quantify the surgical exposure area of the BX through the OCW and COW.The total surgical area increased significantly from steps 1 to 4 (P < .001) in both OCW and COW groups. Overall, there was a larger total surgical area obtained in the COW compared with the OCW (P = .010). ICA mobilization increased the surgical area for temporary (P < .001) and permanent (P < .003) clip application in both windows. The division of PCoA significantly increased the overall surgical area for permanent clip application (P < .003). Compared with the OCW, the COW had a significantly increased change in the area for permanent clip application in the low-lying group (P = .03).When approaching the BX via the pterion route, the appropriate surgical step and window should be selected according to characteristics of the PCoA and height of the BX.
Instrumentation of the posterior thoracolumbar spine: from wires to pedicle screws. - Neurosurgery
Over the past 120 years, spinal stabilization has advanced immensely. An updated review highlighting these advancements has not been performed in the past 20 years. The objective of this report is to provide a historical assessment of the decades outlining various key innovators, their techniques, and instrumentation. It is important to provide new generations of surgeons and students with historical evidence of the value of developing new techniques and instrumentation to improve patient care and outcomes.
Pharmacophysiology of bone and spinal fusion. - The spine journal : official journal of the North American Spine Society
In recent years, the number of complex spinal surgeries has increased significantly in the elderly population, where the prevalence of low bone density is highest. Consequently, spine surgeons often treat osteoporotic patients who are associated with higher rates of instrumentation failure. Therefore, establishing a successful fusion requires an appropriate substrate for bone formation and local bone remodeling. The fusion process can be supported by therapies that seek to shift the balance of bone homeostasis to increased formation and reduced resorption.Thorough understanding of the physiology of bone formation and adjunctive therapies can help improve fusion rates. Therefore, we present a thorough review of the latest pharmacologic agents used to enhance bone strength and surgical spinal fusion.Systematic review of literature.Current knowledge on bone physiology has led to the development of several pharmacologic agents that enhance bone formation and strengthen the human skeleton. At present, natural supplements of vitamin D and calcium or synthetic medications like bisphosphonates are widely used before and after spine surgeries to enhance bone fusion. Additional physiologic agents, including testosterone, parathyroid hormone, calcitonin, and growth hormone, have been shown to improve bone mass density or spinal fusion in both animal and human studies. As in other medical fields, gene therapy has shown viability and promise with the use of both viral and nonviral vectors.Through the understanding of bone physiology, numerous natural and synthetic pharmacologic agents have been developed to enhance the body's skeleton and to improve outcomes of spinal fusion surgery.Copyright Â© 2013 Elsevier Inc. All rights reserved.
The Influence of Common Medical Conditions on the Outcome of Anterior Lumbar Interbody Fusion. - Journal of spinal disorders & techniques
The authors retrospectively reviewed a consecutive series of 231 patients with anterior lumbar interbody fusion (ALIF).To determine the correlations among common medical conditions, demographics, and the natural history of lumbar surgery with outcomes of ALIF.Multiple spinal disorders are treated with ALIF with excellent success rates. Nonetheless, adverse outcomes and complications related to patients' overall demographics, comorbidities, or cigarette smoking have been reported.The age, sex, body mass index (BMI), comorbidities, history of smoking or previous lumbar surgery, operative parameters, and complications of 231 patients who underwent ALIF were analyzed. Regression analyses of all variables with complications and surgical outcomes based on total Prolo scores were performed. Two models predicting Prolo outcome score were generated. The first model used BMI and sex interaction, whereas the second model used sex, level of surgery, presence of diabetes mellitus, and BMI as variables.At follow-up, the rate of successful fusion was 99%. The overall complication rate was 13.8%, 1.8% of which occurred intraoperatively and 12% during follow-up. The incidence of complications failed to correlate with demographics, comorbidities, smoking, or previous lumbar surgery (P>0.5). ALIF at T12-L4 was the only factor significantly associated with poor patient outcomes (P=0.024). Both models successfully predicted outcome (P=0.05), although the second model did so only for males.Surgical level of ALIF correlated with poor patient outcomes as measured by Prolo functional scale. BMI emerged as a significant predictor of Prolo total score. Both multivariate models also successfully predicted outcomes. Surgical or follow-up complications were not associated with patients' preoperative status.
Cervical spinal cord infarction after cervical spine decompressive surgery. - World neurosurgery
To report five patients who underwent cervical decompressive surgeries and developed persistent postoperative neurologic deficits compatible with spinal cord infarctions and evaluate causes for these rare complications.The clinical courses and imaging studies of five patients were retrospectively analyzed. Imaging findings, types of surgeries, vascular compromise or risk factors, hypotensive episodes, intraoperative somatosensory evoked potentials, concomitant brain infarctions, and clinical degree and radiographic extent of spinal cord infarction were studied. The presence of spinal cord infarction was determined by clinical course and imaging evaluation.All five patients had antecedent cervical cord region vascular compromise or generalized vascular risk factors. Four patients developed hypotensive episodes, two intraoperatively and two postoperatively. None of the four patients with hypotensive episodes had imaging or clinical evidence of concomitant brain infarctions.Neuroimaging evaluation of spinal cord infarction after decompressive surgery is done to exclude spinal cord compression, to ensure adequate surgical decompression, and to confirm infarction by imaging. Antecedent, unrecognized preoperative vascular compromise may be a significant contributor to spinal cord infarction by itself or in combination with hypotension.Copyright Â© 2014 Elsevier Inc. All rights reserved.
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