Browsing by Author "Doederlein, Alexander R."
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Item A Case Report of Selective Skip Laminectomies and Subsequent Catheter Irrigation of a Holospinal Epidural Abscess(2022) Doederlein, Alexander R.; Beeton, George; Loeffelholz, Zachary; Sandu, CezarBackground: Holospinal epidural abscesses (HEAs) are exceedingly rare, with less than 25 case reports of the condition found in the literature. Broad-spectrum antibiotics are virtually always indicated in its treatment upon its diagnosis, which is typically made via magnetic resonance imaging (MRI). Furthermore, if fulminant neurological deterioration presents, surgical debridement of the infection can help reduce the infectious burden and improve long-term outcomes. Access to the epidural space is attained via laminectomies; however, extensive laminectomies can destabilize the spine. Various case reports noted that selective laminectomies at particular vertebrae can avoid this destabilization, while still allowing catheter access to the length of the spinal cord. Case Information: Our patient was a 60-year-old male who presented with altered mental status, neck pain, and fever. He was diagnosed with methicillin-resistant Staphylococcus aureus meningitis and bacteremia. An MRI revealed an epidural abscess running from the cervical spine through the lumbar spine with concomitant compression of the spinal cord, as well as numerous paraspinal musculature abscesses and a retropharyngeal/prevertebral abscess. The patient was started on broad-spectrum IV antibiotics; however, his condition continued to deteriorate. The decision was made to perform a surgical debridement. Laminectomies were performed at vertebrae T4 and T10, and catheters were then run cranially and caudally through these points to access the length of the spinal canal. The purulent material was aspirated, and an antibiotic solution was then used to irrigate the epidural space; meanwhile, the patient was cycled between Trendelenburg and Reverse Trendelenburg positions to facilitate drainage of the purulent material. Following the procedure, the patient's neurological status started to improve. He was kept on vancomycin postoperatively until his elevated inflammatory markers resolved. The patient recovered fully, and at three months follow-up had no neurological deficits. Conclusions: This surgical technique is an effective way to identify the inciting organism in a HEA, reduce the infectious burden, decompress the spinal cord, minimize surgical time and blood loss, and maintain stability of the spine without the use of instrumentation.Item Altered Balance in those with Back Pain(2022) Doederlein, Alexander R.; Kennedy, Shawn; Patterson, RitaPurpose: Numerous studies have attempted to find an association between back pain (BP) and altered standing balance. These quiet standing (QS) studies measure a subject's center of pressure (COP) via a force plate system. From the COP data, variables such as COP area and COP velocity are calculated to measure the amount of sway a subject had while attempting to stand still during the QS trial. In reviewing previous research, most studies had relatively small sample sizes, and while some were able to achieve statistically significant differences in sway variables between subjects with BP and healthy controls, most were too underpowered to achieve clinical statistical significance. Also, what is concerning is that some studies with shared variables had inconsistent results of whether BP or healthy control participants had greater values. Our study sought to test potential associations with a much larger sample size (greater than 10-fold larger than many other studies) to find clinically meaningful relationships. Methods: This research is built from the results of previous QS studies and an ongoing QS project at UNTHSC. A Bertec force plate (Bertec, Columbus, Ohio) was used to collect data from participants standing quietly on it for a period of 30 seconds with their eyes open (EO), and then 30 seconds with their eyes closed (EC). Each 30 second period was collected as three 10 second trials for each condition. This study's data was collected from people suffering from BP and healthy controls. Results: COP area was statistically significantly greater for BP subjects, however, only during EC trials. In contrast, during EO trials, the COP area was not statistically different between the two groups. Furthermore, in distinction from previous studies, velocity was statistically significantly greater for healthy controls regardless of the trial's eye condition. Conclusions: These results led us to hypothesize that during the EC trials, BP subjects cover a greater COP area than the controls due to decreased proprioception, in which they sway further from their balance point before being able to detect they are moving. However, in EO trials, this area is not statistically different, likely because BP subjects have learned to compensate for their decreased proprioception by relying more on their vision for positional sense. Furthermore, since the healthy controls exhibited a greater velocity than the BP subjects, this could mean that the BP subjects are taking longer to regain their balance due to decreased reflexes. In conclusion, we suggest that future QS studies screen subjects for delays in reflexes, a lesser sense of proprioception, and whether lighting conditions create altered sway outcomes. This study contributes precautionary information to help prevent falls in those with BP.Item Candidate gene analysis of 535 "pain genes" and associations with reported intensity of chronic low back pain(2022) Hurd, Christine A.; Phillips, Nicole R.; Lin, Emily; Broadbent, Dallen; Doederlein, Alexander R.; Dubakula, Vishnu; Licciardone, John C.Purpose: Numerous genome-wide association studies have been able to elucidate potential underlying genetic associations with clinical diagnoses. Chronic low back pain (CLBP) is a clinical presentation that has not yet been strongly associated with specific genetic markers. Several studies however have found genetic associations with other various pain disorders, such as the 535 genes identified by Ultsch et al. as "pain genes." Our group aims to find associations between previously identified pain-related genes and clinical reports of the intensity of low back pain using genetic and clinical data collected by the PRECISION Pain Research Registry. Methods: The PRECISION Pain Research Registry is a national registry that has collected demographic, clinical, and genetic information of patients with CLBP. Our analysis is querying associations between these identified "pain genes" and the intensity of low back pain reported by registry participants using a numerical rating scale (NRS). Methods: Participants in the PRECISION Pain Research Registry were genotyped via an Illumina iScan Array Scanner and Global Screening Array. The phenotype of CLBP will be measured by the NRS, which is an 11-point quantifier of pain intensity. The collected genotypes and phenotypic expression of pain will be compared via the Multi-marker Analysis of GenoMic Annotation (MAGMA), which enables candidate gene analysis of the 535 "pain genes" via congregation of single nucleotide polymorphisms (SNPs) and subsequent projection onto principal components in a matrix. Pain intensity will be evaluated as a function of genetic effects accounting for selected covariates-comorbid conditions with a documented relationship to CLBP, smoking status, and genetic ancestry plus residuals, with F-tests to determine the p-values of associations. Results: FN1 and STARD13 were found to be significantly associated with pain intensity in AA registry participants and VEGF-A was found to be significantly associated with widespread pain in NHW registry participants Conclusion: For treatment that is refractory to other strategies, targeted drugs for these protein products can be explored as treatments. These mentioned genes also have significant epigenetic regulation that could be explored in further studies.Item The Incidence of Distal Extremity Necrosis Associated with Vasopressor use in Critically Ill Patients(2023) Beeton, George; Doederlein, Alexander R.; Loeffelholz, Zachary; Pientka, William; Pientka, AmandaPurpose: Medication adverse events are associated with significant morbidity and mortality, increased hospital length of stay, and create a high burden of cost for both the patient and the healthcare system. Vasopressors are a class of medication with a known association with digital necrosis due to excessive peripheral vasoconstriction, in order to prioritize blood flow to the vital organs. We aim to identify the incidence of distal extremity necrosis in critically ill patients receiving vasopressors for cardiovascular support. Methods: A retrospective analysis was performed of all patients treated with vasopressors including epinephrine, norepinephrine, phenylephrine, and vasopressin during the study period: January 1, 2012, through December 31, 2020, at a single institution. Patients treated with vasopressors with a concomitant documented diagnosis of distal extremity (upper and/or lower) ischemia, gangrene, or necrosis were identified. This subset of patients underwent further chart review to confirm the onset of digital necrosis was within 4 months of vasopressor use. The incidence of distal extremity necrosis in critically ill patients receiving vasopressors for cardiovascular support was then calculated. Results: A total of 1,980,300 patients were screened, of which 46,792 had documented vasopressor use and were included in the at-risk population. Of all patients that had received vasopressors within our study period, 1,151 also had a documented diagnosis of distal extremity necrosis. Overall, a total of 56 (0.12%) patients had documented distal extremity necrosis within 4 months after sustained vasopressor use. 31 patients (36.1%) were given 3 or 4 vasopressors concurrently, 28 (50%) had isolated toe and/or foot necrosis, 15 (26.8%) had necrosis of both the distal upper and lower extremities, and 13 (23.2%) developed necrosis isolated to the hand and/or fingers. The average age of those who developed digital necrosis was 59 years. While there was more distal extremity necrosis when multiple pressors were used concurrently, the association was not significant (p=0.77) Conclusion: The use of vasopressors for cardiac support in critically ill patients is often unavoidable. This treatment comes with the risk of inducing distal extremity ischemia and necrosis. The incidence of distal extremity necrosis is extremely low, but the risk increases when multiple vasopressors are used concurrently.