Patient-reported QOL end points are becoming increasingly

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1 J Neurosurg 119: , 2013 AANS, 2013 Prospective validation of a patient-reported nasal quality-of-life tool for endonasal skull base surgery: The Anterior Skull Base Nasal Inventory-12 Clinical article Andrew S. Little, M.D., 1 Daniel Kelly, M.D., 2 John Milligan, M.D., 1 Chester Griffiths, M.D., 2 Gail Rosseau, M.D., 4 Daniel M. Prevedello, M.D., 3 Ricardo Carrau, M.D., 3 Heidi Jahnke, R.N., M.S.N., 1 Charlene Chaloner, R.N., 2 Judith O Leary, R.N., 4 Kristina Chapple, Ph.D., 1 Peter Nakaji, M.D., 1 and William L. White, M.D. 1 1 Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph s Hospital and Medical Center, Phoenix, Arizona; 2 Brain Tumor Center, John Wayne Cancer Institute, Santa Monica, California; 3 Department of Neurosurgery, The Ohio State University, Columbus, Ohio; and 4 Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois Object. Patient-reported quality-of-life (QOL) end points are becoming increasingly important health care metrics. To date, no nasal morbidity instrument specifically designed for patients undergoing endonasal skull base surgery has been developed. In this study, the authors describe the development and validation of a site-specific nasal morbidity instrument to assess patient-reported rhinological outcomes following endonasal skull base surgery. Methods. Eligible patients included those with planned endonasal transsphenoidal surgery for sellar pathology identified in outpatient neurosurgical clinics of 3 skull base centers from October 2011 to July An initial 23-question pool was developed by subject matter experts, review of the literature, and from the results of a previous validation study to assess for common rhinological complaints. Symptoms were ranked by patients from No Problem to Severe Problem on a 6-point Likert scale. Exploratory factor analysis, change scores, and importance rank were calculated to define the final instrument consisting of 12 items (The Anterior Skull Base Nasal Inventory-12, or ASK Nasal-12). Psychometric validation of the final instrument was performed using standard statistical techniques. Results. One hundred four patients enrolled in the study. All patients completed the preoperative survey and 100 patients (96%) completed the survey 2 4 weeks after surgery. Internal consistency of the final instrument was Concurrent validity measures demonstrated a strong correlation between overall nasal functioning and total scores (p < 0.001). Test-retest reliability measures demonstrated a significant intraclass correlation between responses (p < 0.001). Effect size as calculated by standardized response mean suggested a large effect (0.84). Discriminant validity calculations demonstrated that the instrument was able to discriminate between preoperative and postoperative patients (p < 0.001). Conclusions. This prospective study demonstrates that the ASK Nasal-12 is a validated, site-specific, unidimensional rhinological outcomes tool sensitive to clinical change. It can be used in conjunction with multidimensional QOL instruments to assess patient-reported nasal perceptions in endonasal skull base surgery. This instrument is being used as a primary outcome measure in an ongoing multicenter nasal morbidity study. Clinical trial registration no.: NCT (ClinicalTrials.gov). ( Key Words nasal outcome endoscopic surgery quality of life Abbreviations used in this paper: ASBQ = Anterior Skull Base Questionnaire; ASK Nasal-12 = Anterior Skull Base Nasal Inventory-12; QOL = quality of life; SNOT = Sinonasal Outcome Test. Patient-reported QOL end points are becoming increasingly important clinical metrics to supplement traditional objective outcome measures. Quality of life is a measure of a patient s sense of well being and includes multiple domains, such as emotions, pain, functional status, and social interactions. Endonasal skull base surgery is gaining popularity as an alternative to conventional open approaches, partially because of the perception of decreased approach-related morbidity and improved QOL. 1,19 Because these approaches exploit the nasal corridor and paranasal sinuses to reach the skull base, nasal trauma is a primary source of postoperative morbidity in many of these patients. Reported rhinological complications include sinusitis, synechiae, anosmia, 1068 J Neurosurg / Volume 119 / October 2013

2 The Anterior Skull Base Nasal Inventory-12 epistaxis, septal perforation, and nasal congestion, which may affect nasal functioning and patient satisfaction with surgery. 6,7,15,24 Central to the effort of determining the impact of rhinological morbidity on QOL is the development of a validated nasal morbidity instrument constructed specifically for the population undergoing endonasal skull base surgery. Despite the proliferation and widespread adoption of endonasal skull base techniques, only recently have centers begun to investigate QOL concerns. 4,10,20,21 Current reports are limited by the use of QOL scales that either do not assess nasal complaints 13 or were not developed or validated for endonasal skull base surgery. 13,17,22 Furthermore, neurosurgeons should be familiar with the nasal morbidity of these techniques to aid in preoperative and postoperative patient counseling and to help place their approach-related morbidity in the context of open skull base techniques. Claims have been made that endonasal surgery is minimally invasive, but this has not been rigorously evaluated. A better understanding of the morbidity with this type of surgery is needed, as these techniques are now a standard part of the neurosurgical skull base armamentarium. In this study, we describe the development of the first approach-specific rhinological morbidity instrument for endonasal skull base surgery, the ASK Nasal-12, to complement other multidimensional QOL scales. This research effort used a multistep validation process that included creating a preliminary scale, 18 refining and expanding the instrument based on patient and expert feedback, and completing final validation in a multicenter prospective study. Methods This prospective multicenter study was approved by the institutional review boards at the participating institutions and registered with ClinicalTrials.gov (no. NCT ). Patient Population Eligible patients were consecutive English- or Spanish-speaking adults identified in the outpatient neurosurgical clinics at 3 skull base centers (Barrow Neurological Institute, Northshore University HealthSystem, and the John Wayne Cancer Institute) between October 2011 and July These patients had sellar pathology and a planned primary or secondary endonasal surgical approach using the transsphenoidal corridor. Patients with a history of prior radiotherapy to the paranasal sinus region or skull base were excluded. A total of 146 patients were screened for eligibility; 38 patients were not eligible for the study and 4 patients declined to participate. Survey Administration The survey was self-administered by patients within 2 weeks before surgery in the neurosurgical clinic and then at the first postoperative clinic visit 2 4 weeks after surgery. A research nurse provided the written instrument to the patient and was available for assistance. Survey responses were collated by the research nurse and entered into an Excel database for analysis. J Neurosurg / Volume 119 / October 2013 Statistical Analysis The strategy of selecting items for inclusion in the scale and validation of the scale was based on the methods used for development of the ASBQ and SNOT instruments. 12,17 Exploratory factor analyses were conducted using maximum likelihood estimation. Variance accounted for and factor loadings presented are from the varimax rotated model. Internal consistency of the ASK Nasal-12 was determined using the Cronbach a. 9 Discriminant validity was evaluated at the item level and at the subscale level. Paired sample t-tests were used to calculate discriminant validity of our measure from pre- to postsurgery to examine the discrimination of each item. Effect sizes were obtained using a standardized response mean from t-tests. Concurrent validity was measured using the Spearman rho (r) correlation between the overall nasal functioning item and the mean of the total scale calculated without the overall functioning item. Test-retest reliability was measured by the average intraclass correlation coefficient. Statistical evaluation was performed by a doctorally trained biostatistician (K.C.) using SPSS version 20. Results Instrument Development and Content Validation The ASK Nasal-12 was developed using a multistep process outlined in Fig. 1. As the first step, a preliminary 9-item tool was developed. 18 During the validation process of this instrument, we discovered opportunities for enhancements, and therefore initiated the study reported herein to improve the scale. As part of this process, we engaged 4 additional subject matter experts in otolaryngology and neurosurgery, learned from the critiques of reviewers during the formal manuscript review process, conducted patient exit interviews for feedback, and reexamined current literature that had been published since the beginning of this project. 10,21 As a result of this process, we made 3 main modifications to the preliminary instrument. First, we created a larger pool of questions addressing potential patient complaints that might impact QOL. Second, we expanded the 5-point rating scale to a 6-point rating scale to facilitate better discrimination of mild to moderate symptoms; we learned in the first study that most patients rated their symptoms as mild to moderate. Third, we changed the rating scale to one based on symptom severity rather than symptom frequency. A revised pool of 23 questions focusing on common postoperative nasal complaints was developed. Patients were asked to score the severity of each symptom on a 6-point Likert scale (0 = no problem to 5 = very severe problem) and also to rank the 5 symptoms that were most important to them after surgery. One hundred four patients enrolled in the study and completed the preoperative questionnaire, and 100 (96%) patients completed the follow-up questionnaire within 2 4 weeks of surgery. Characteristics of the patient cohort are presented in Table 1. Preoperative, postoperative, and mean change scores were calculated for each question (Fig. 2; Table 2) along 1069

3 A. S. Little et al. Fig. 1. Flow diagram demonstrating the multistep process of content validation and psychometric validation of the ASK Nasal-12 nasal outcomes tool. with the percentage of patients ranking each symptom as important. Sensory symptoms, nasal obstruction symptoms, and nasal discharge symptoms had the greatest magnitude of worsening (p < 0.001), based on the mean change scores. In contrast, 4 symptoms demonstrated no significant change after surgery: dizziness, ear pain, nose bleeds, and eye tearing (p > 0.1). The symptoms rated most important to patients lives included sense of smell, headache, and symptoms of nasal obstruction. Symptoms rated least important included nose whistling, teeth and ear pain, nose bleeds, and sound of voice. Face Validity Exploratory factor analysis was used to examine the factor structure of the instrument and to provide face validity of our measure. Factor loadings greater than 0.50 were retained, resulting in a 2-factor, 11-item measure. Latent constructs of the final measure were of a 2-factor solution, which we have labeled the symptom subscale and sensory subscale, and that accounted for 38.0% and 17.6% of variance, respectively. Together, these subscales accounted for 57.6% of the variance in the scores. The means, standard deviations, and standardized factor loadings for all items are presented in Table 2. Patients ratings of important symptoms were also considered in determining which items would be included in the final version. Although the factor loading for headache was less than the 0.50 cutoff, headache was rated the second most important symptom by patients and considered important by clinicians associated with the study. The final instrument included 8 of 10 symptoms ranked most important by patients and 9 of 10 symptoms with the greatest worsening after surgery. All symptoms included in the survey demonstrated statistically significant worsening following surgery. Internal Consistency Internal consistency of the ASK Nasal Inventory was determined using the Cronbach a before and after surgery for the initial 23-item survey, the final 12-item survey, and subscales of the final 12-item version. The Cronbach a (Table 2) ranged from 0.71 to 0.95, all suggestive of good internal consistency. Removal of any of the 12 questions did not significantly improve the internal consistency, suggesting that no question was substantially inconsistent with the others (data not shown). Discriminant Validity Values for 11 of the 12 items on the final scale were significantly higher after surgery, suggesting symptomatic worsening (Table 2). Headache trended toward signifi J Neurosurg / Volume 119 / October 2013

4 The Anterior Skull Base Nasal Inventory-12 TABLE 1: Preoperative characteristics of 104 patients undergoing endonasal skull base surgery* Characteristic Value (%) age (yrs) mean 52 range sex males 48 (46) females 56 (54) pathology nonfunctioning adenoma 58 (56) acromegaly 13 (13) prolactinoma 13 (13) Cushing disease 8 (8) TSH-producing tumor 1 (1) other 11 (11) prior surgery 9 (9) * Values represent the number of patients (%) unless otherwise indicated. Abbreviation: TSH = thyroid-stimulating hormone. Other includes Rathke cleft cyst, meningioma, craniopharyngioma, and metastasis. cance (p = 0.058). The mean total score was also significantly higher after surgery compared with before surgery (p < 0.001; Table 2). Together these findings indicate that the items discriminate postoperative nasal functioning from preoperative nasal functioning. Effect Size A standardized response mean was used to estimate effect size. The standardized response mean of our 12- item scale from presurgery to postsurgery was The standardized response mean calculation suggests a large effect. 8 Test-Retest Reliability The ASK Nasal-12 was administered to 20 patients 3 months after surgery and then approximately 2 weeks later (median 15 days, interquartile range days) to examine test-retest reliability. A significant intraclass correlation between responses emerged, providing evidence of instrument stability (intraclass correlation coefficient = 0.90, 95% CI ; p < 0.001). In the reliability group, as expected, none of the items changed significantly from the first to the second survey administration. Concurrent Validity Concurrent validity was determined by correlation of the postoperative mean ASK Nasal-12 scores, calculated without the overall functioning item and with the overall functioning item postoperatively. 17,18 There was a strong correlation between mean ASK Nasal-12 score and overall functioning (r = 0.64, 95% CI ; p < 0.001). Discussion In this study we describe the development and multicenter validation of a unidimensional, site-specific, nasal morbidity instrument designed specifically for patients undergoing endonasal anterior cranial base surgery through the endonasal transsphenoidal corridor. The transsphenoidal corridor represents the most commonly used corridor for accessing skull base pathology. The ASK Nasal-12 was developed to assess patient perception of nasal morbidity, one of the primary sources of morbidity after endonasal surgery. The validation process narrowed a pool of 23 questions to 12 questions that were most important to patients and that reflected significant worsening after surgery. This prospective study demonstrates that the final 12-item scale is sensitive to clinical change and fulfills psychometric criteria for internal consistency, discriminant validity, test-retest reliability, and concurrent validity. The ASK Nasal-12 represents the culmination of a Fig. 2. Bar graph showing change scores (postoperative score - preoperative scores) for 23 items from the question pool. Positive scores indicate worsening of symptoms. Black bars represent items on the final scale. J Neurosurg / Volume 119 / October

5 A. S. Little et al. TABLE 2: Item characteristics before and after surgery, and scale validation after surgery Variable Preop* Postop* 95% CI of Difference Patient Importance (%) Factor Loading Item Total Correlation symptom subscale 0.86 ± ± urge to blow nose 0.94 ± ± postnasal discharge 0.91 ± ± thick nasal discharge 0.54 ± ± headache 1.92 ± ± nose whistling 0.25 ± ± dried nasal material 0.96 ± ± trouble breathing: day 0.49 ± ± trouble breathing: night 1.02 ± ± trouble breathing equally through nostrils 0.84 ± ± overall nasal functioning 0.74 ± ± Cronbach α sensory subscale 0.35 ± ± sense of smell 0.45 ± ± sense of taste 0.23 ± ± Cronbach α item scale 0.80 ± ± Cronbach α items not in final scale sneezing 0.81 ± ± facial pain pressure 0.70 ± ± sound of voice 0.28 ± ± cough 0.67 ± ± numbness in upper front teeth 0.08 ± ± ear fullness 0.48 ± ± foul smell inside nose 0.07 ± ± dizziness 0.92 ± ± ear pain 0.32 ± ± nose bleeds 0.44 ± ± excessive eye tearing 0.67 ± ± to * All values given as mean ± SD unless otherwise indicated. Percentage of patients ranking the symptom as important to them after surgery. Probability values < for all symptom subscale variables, except for headache (p = 0.058). Probability values < for all variables. Probability values < for sneezing, facial pain pressure, sound of voice, cough, numbness in upper front teeth, and ear fullness; p < 0.01 for foul smell inside nose; all other variables not significant. multistep and iterative process to develop a validated nasal morbidity instrument for endonasal skull base surgery. Based on our initial experience with the ASK Nasal-9 18 and by incorporating patient and expert feedback, we went back to the drawing board and rebuilt the tool by expanding the question pool, engaging additional subject matter experts, and modifying its symptom assessment to incorporate severity rather than just frequency. We believe that the iterative process we used to validate the tool adds to its validity as the process allowed for enhancements to be made along the way. The ASK Nasal-12 was completely revalidated in a rigorous multicenter nasal morbidity study, the first of its kind in endonasal skull base surgery. The questions regarding nasal morbidity in endonasal skull base surgery have only recently begun to be addressed despite the proliferation and general acceptance of these techniques. 10,12,16,19 21,23,25 These studies have at least 1 of several important limitations, including retrospective analysis of data, interpretation of unpaired postoperative data, use of nonvalidated outcome measures, and application of scales developed for other disease entities in unrelated patient populations. In this study, we sought to address the latter 2 limitations. It is our contention that QOL studies in endonasal skull base surgery would benefit from the development of an instrument designed and validated with this population of patients in mind. The ASK Nasal-12 scale offers several improvements to the QOL scales used previously. For example, the most 1072 J Neurosurg / Volume 119 / October 2013

6 The Anterior Skull Base Nasal Inventory-12 commonly used rhinological scale used is the SNOT, a disease-specific instrument developed for assessment of QOL in patients with rhinosinusitis. 17,22 Our work suggests that its primary limitation is one of content validation. The SNOT does not assess some of the most relevant postoperative symptoms associated with endonasal skull base surgery and does evaluate symptoms that are less important to our patients. For instance, the SNOT-20 does not assess for sense of smell and taste, headache, dried nasal crusts, and nasal whistling, which our work demonstrated are important to patients and which worsen initially after surgery. However, the SNOT-20 does assess for ear-related symptoms and sneezing, which are important in rhinosinusitis, but which our work suggests are not as important to patients undergoing endonasal skull base surgery. The other commonly used scale is the ASBQ. The ASBQ is a 35-question disease-specific multidimensional instrument developed by Gil and colleagues 13 to assess QOL in patients with sinonasal and anterior cranial base pathology addressed through an open cranial approach. This well-validated scale assesses 6 domains including performance, physical functioning, vitality, emotion, pain, and specific symptoms. It is a valuable tool for improving our understanding of QOL after skull base surgery. However, its primary shortcoming in its application to endonasal surgery is that it does not specifically assess nasal morbidity, one of the key sources of morbidity after this type of surgery. 1,2,11 14 A nasal morbidity scale such as the ASK Nasal-12, which complements existing multidimensional QOL instruments, may be a useful clinical and research tool. The clinical application of the ASK Nasal-12 requires additional comment. In the ASK Nasal-12, each question is assumed to be weighted equally and scored on a 6-point Likert scale (0 5). The total score is obtained by summing the scores of each question, with a total possible score ranging from 0 to 60. Higher scores indicate higher patient-reported nasal morbidity. The scale can be completed in person, by , or over the phone in about 2 minutes. We have also translated it into Spanish. Exploratory factor analysis suggested that the scale has 2 subdomains, but 1 domain only includes 2 items. We recommend reporting results as an overall score rather than breaking the scale into subdomains until understanding of the subdomains improves. Finally, the ASK Nasal-12 was developed for use in conjunction with other well-validated multidimensional QOL scales, such as the ASBQ or Short-Form Health Surveys. 3,5 Because these excellent multidimensional tools already exist, we did not believe that it was necessary to develop another multidimensional tool; rather, we focused on studying nasal morbidity. We envision that the ASK Nasal-12 can be used for future research endeavors and for the longitudinal evaluation of patients in routine clinical practice. Our hope is that the ASK Nasal-12 will help us to meaningfully address some of the more intriguing technical questions associated with endonasal skull base surgery, such as differences in nasal morbidity between microscopic approaches and endoscopic approaches, the morbidity of middle turbinate resection versus outfracture, and a comparison of uninostril versus binostril techniques. To address some of these questions, J Neurosurg / Volume 119 / October 2013 the ASK Nasal-12 is being applied as 1 end point in an ongoing multicenter QOL study. This study will address the rhinological outcomes of microscopic and fully endoscopic endonasal techniques and is being conducted at 4 US centers. Conclusions In this prospective study, we developed and validated a site-specific, unidimensional QOL scale that assesses nasal morbidity after endonasal skull base surgery. Our data demonstrate that the ASK Nasal-12 is sensitive to clinical change and fulfills parameters for psychometric validity. The ASK Nasal-12 addresses the limitations of currently used sinonasal outcome scales and multidimensional QOL measures. It can be used as a complement to other QOL instruments for the purposes of research and clinical practice. The ASK Nasal-12 is being applied as 1 end point in an ongoing multicenter QOL study. Disclosure Dr. Little has received a teaching honorarium from Johnson & Johnson. Dr. Kelly has received royalties from Mizuho. Dr. Prevedello has received material and equipment for support of his lab from Stryker, Storz, Medtronic, KLS-Martin, and Vycor Medical. Dr. Nakaji is a consultant for Medtronic and Aesculap. The Barrow Neurological Foundation provided support for this research. Author contributions to the study and manuscript preparation include the following. Conception and design: Little, Kelly, Milligan, Griffiths, Rosseau, Prevedello, Carrau, Nakaji, White. Acquisition of data: Jahnke, Chaloner, O Leary. Analysis and interpretation of data: Little, Kelly, Chapple. Drafting the article: Little, Kelly, Chapple. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Little. Statistical analysis: Chapple. Administrative/technical/material support: Jahnke. Study supervision: Little. Acknowledgment The authors thank the staff of the Neuroscience Publications Office at St. Joseph s Hospital for assistance with manuscript preparation and editing. References 1. 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7 A. S. Little et al. transsphenoidal approach for pituitary adenomas. J Neurosurg 97: , Charalampaki P, Ayyad A, Kockro RA, Perneczky A: Surgical complications after endoscopic transsphenoidal pituitary surgery. J Clin Neurosci 16: , Cohen J: Statistical Power Analysis for the Behavioral Sciences, ed 2. Hillsdale, NJ: Lawrence Erlbaum Associates, Cronbach LJ, Warrington WG: Time-limit tests: estimating their reliability and degree of speeding. Psychometrika 16: , de Almeida JR, Snyderman CH, Gardner PA, Carrau RL, Vescan AD: Nasal morbidity following endoscopic skull base surgery: a prospective cohort study. Head Neck 33: , Gil Z: Quality of life in patients with skull base tumors. Skull Base 20:1, Gil Z, Abergel A, Spektor S, Cohen JT, Khafif A, Shabtai E, et al: Quality of life following surgery for anterior skull base tumors. Arch Otolaryngol Head Neck Surg 129: , Gil Z, Abergel A, Spektor S, Shabtai E, Khafif A, Fliss DM: Development of a cancer-specific anterior skull base qualityof-life questionnaire. J Neurosurg 100: , Gil Z, Fliss DM: Quality of life in patients with skull base tumors: current status and future challenges. Skull Base 20:11 18, Gondim JA, Almeida JP, Albuquerque LA, Schops M, Gomes E, Ferraz T, et al: Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary 14: , Graham SM, Iseli TA, Karnell LH, Clinger JD, Hitchon PW, Greenlee JD: Endoscopic approach for pituitary surgery improves rhinologic outcomes. Ann Otol Rhinol Laryngol 118: , Hopkins C, Gillett S, Slack R, Lund VJ, Browne JP: Psychometric validity of the 22-item Sinonasal Outcome Test. Clin Otolaryngol 34: , Little AS, Jahnke H, Nakaji P, Milligan J, Chapple K, White WL: The anterior skull base nasal inventory (ASK nasal inventory): a clinical tool for evaluating rhinological outcomes after endonasal surgery for pituitary and cranial base lesions. Pituitary 15: , McCoul ED, Anand VK, Bedrosian JC, Schwartz TH: Endoscopic skull base surgery and its impact on sinonasal-related quality of life. Int Forum Allergy Rhinol 2: , McCoul ED, Anand VK, Schwartz TH: Improvements in site-specific quality of life 6 months after endoscopic anterior skull base surgery: a prospective study. Clinical article. J Neurosurg 117: , Pant H, Bhatki AM, Snyderman CH, Vescan AD, Carrau RL, Gardner P, et al: Quality of life following endonasal skull base surgery. Skull Base 20:35 40, Piccirillo JF, Merritt MG Jr, Richards ML: Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg 126:41 47, Suberman TA, Zanation AM, Ewend MG, Senior BA, Ebert CS Jr: Sinonasal quality-of-life before and after endoscopic, endonasal, minimally invasive pituitary surgery. Int Forum Allergy Rhinol 1: , Urquhart AC, Bersalona FB, Ejercito VS, Holt JJ: Nasal septum after sublabial transseptal transsphenoidal pituitary surgery. Otolaryngol Head Neck Surg 115:64 69, Zada G, Kelly DF, Cohan P, Wang C, Swerdloff R: Endonasal transsphenoidal approach for pituitary adenomas and other sellar lesions: an assessment of efficacy, safety, and patient impressions. J Neurosurg 98: , 2003 Manuscript submitted October 25, Accepted March 21, Please include this information when citing this paper: published online May 10, 2013; DOI: / JNS Address correspondence to: Andrew S. Little, M.D., c/o Neuroscience Publications, Barrow Neurological Institute, St. Joseph s Hospital and Medical Center, 350 West Thomas Road, Phoenix, Arizona neuropub@dignityhealth.org J Neurosurg / Volume 119 / October 2013