Patterns and predictors of anxiety and depression symptom trajectories in patients diagnosed with primary brain tumors.

BACKGROUND: Patients with primary brain tumors (pPBTs) often exhibit heightened distress. This study assesses how symptoms of anxiety and depression change over time in pPBTs and identifies factors that may predict patients' symptom trajectories. METHODS: Ninety-nine adult pPBTs completed psychosocial assessments at neuro-oncology appointments over 6-18 months. Quality of life was assessed with the Functional Assessment of Cancer Therapy-Brain; symptoms of anxiety and depression were assessed with the Patient-Reported Outcomes Measurement Information System short forms. The prevalence of patients with clinically elevated symptoms and those who experienced clinically meaningful changes in symptoms throughout follow-up were examined. Linear mixed-effects models evaluated changes in symptoms over time at the group level, and latent class growth analysis (LCGA) evaluated changes in symptoms over time at the individual level. RESULTS: At enrollment, 51.5% and 32.3% of patients exhibited clinically elevated levels of anxiety and depression, respectively. Of patients with follow-up data (n = 74), 54.1% and 50% experienced clinically meaningful increases in anxiety and depression scores, respectively. There were no significant changes in anxiety or depression scores over time, but better physical, functional, and brain-cancer well-being predicted lower levels of anxiety and depression (p < 0.001). Five sub-groups of patients with distinct symptom trajectories emerged via LCGA. CONCLUSIONS: pPBTs commonly experience elevated symptoms of anxiety and depression that may fluctuate in clinically meaningful manners throughout the disease. Routine screening for elevated symptoms is needed to capture clinically meaningful changes and identify factors affecting symptoms to intervene on.

Defensive medicine among neurosurgeons in the Netherlands: a national survey.

OBJECTIVE: In defensive medicine, practice is motivated by legal rather than medical reasons. Previous studies have analyzed the correlation between perceived medico-legal risk and defensive behavior among neurosurgeons in the United States, Canada, and South Africa, but not yet in Europe. The aim of this study is to explore perceived liability burdens and self-reported defensive behaviors among neurosurgeons in the Netherlands and compare their practices with their non-European counterparts. METHODS: A survey was sent to 136 neurosurgeons. The survey included questions from several domains: surgeon characteristics, patient demographics, type of practice, surgeon liability profile, policy coverage, defensive practices, and perception of the liability environment. Survey responses were analyzed and summarized. RESULTS: Forty-five neurosurgeons filled out the questionnaire (response rate of 33.1%). Almost half (n = 20) reported paying less than 5% of their income to annual malpractice premiums. Nearly all respondents view their insurance premiums as a minor or no burden (n = 42) and are confident that in their coverage is sufficient (n = 41). Most neurosurgeons (n = 38) do not see patients as "potential lawsuits". CONCLUSIONS: Relative to their American peers, Dutch neurosurgeons view their insurance premiums as less burdensome, their patients as a smaller legal threat, and their practice as less risky in general. They are sued less often and engage in fewer defensive behaviors than their non-European counterparts. The medico-legal climate in the Netherlands may contribute to this difference.

Transsphenoidal surgery for Rathke's cleft cyst can reduce headache severity and frequency.

PURPOSE: The purpose of this study was to determine the effect of transsphenoidal surgery for Rathke's cleft cyst(RCC) on headache frequency, severity, and duration. METHODS: The medical records of 43 consecutive patients who underwent transsphenoidal resection of a pathologically-proven RCC at our institution by the senior author (E.R.L.) between April 2008 and April 2014 were reviewed. Patients were called by telephone and asked to answer questions about the severity, location, type, duration,and quality of their headaches, both pre- and postoperatively.This information was joined with detailed data collected directly from each patient's medical record regarding headaches upon presentation and at 1-week,6-week, 3-month, and annual post-operative appointments. RESULTS: Twenty-three patients (53 %) responded to our telephone survey after repeated attempts at contact. Median follow-up was 64 months (range 6­83 months). Of these patients, 19 (82.6 %) reported pre-operative headaches,compared to 12 (52.2 %) who reported post-operative headaches (OR = 1.75, p = 0.02). Average headache severity on a 1­10 scale decreased from 6.4 (SD = 2.0)pre-operatively to 3.4 (SD = 1.9) post-operatively (p = 0.006), while average maximum severity decreased from 8.6 (SD = 2.2) pre-operatively to 4.0 (SD = 3.3)post-operatively (p<0.001). The frequency of headaches also decreased, from 18.1 (SD = 12.6) per month pre-operatively to 3.7 (SD = 8.4) per month post-operatively(p<0.001). Overall, 14 patients (60.9 %) reported improvement in their headaches, and three patients(13.0 %) reported that their headaches had completely resolved. CONCLUSIONS: In a carefully selected patient population,transsphenoidal surgery for RCC can reduce headache monthly frequency, average typical severity, and average maximum severity with minimal risk of morbidity or mortality.

The Neurocritical and Neurosurgical Care of Subdural Hematomas.

Subdural hematomas (SDHs), though frequently grouped together, can result from a variety of different etiologies, and therefore many different subtypes exist. Moreover, the high incidence of these lesions in the neurocritical care settings behooves practitioners to have a firm grasp on their diagnosis and management. We present here a review of SDHs, with an emphasis on how different subtypes of SDHs differ from one another and with discussion of their medical and surgical management in the neurocritical care setting. In this paper, we discuss considerations for acute, subacute, and chronic SDHs and how presentation and management may change in both the elderly and pediatric populations. We discuss SDHs that arise in the setting of anticoagulation, those that arise in the setting of active cerebrospinal fluid diversion, and those that are recurrent and recalcitrant to initial surgical evacuation. Management steps reviewed include detailed discussion of initial assessment, anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring. Direct surgical management options are reviewed, including open craniotomy, twist-drill, and burr-hole drainage and the usage of subdural drainage systems. SDHs are a common finding in the neurocritical care setting and have a diverse set of presentations. With a better understanding of the fundamental differences between subtypes of SDHs, critical care practitioners can better tailor their management of both the patient's intracranial and multi-systemic pathologies.

Frailty, Myelopathy, and Enhanced Recovery After Surgery (ERAS) in Patients Undergoing Posterior Cervical Fusion (PCF).

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) protocol is a proven method to improve postsurgical outcomes. While recent studies have shown the benefit of ERAS even in frail patient populations, myelopathy is another factor affecting outcomes in patients undergoing Posterior Cervical Fusion (PCF). This study evaluated the benefit of an ERAS protocol in frail patients undergoing PCF. METHODS: A retrospective chart review identified consecutive patients undergoing PCF by a single surgeon from August 2015-July 2021, with implementation of ERAS in December 2018. Outcome measures included length of stay (LOS), non-home discharge disposition, complications, return of physiologic function, and severe pain score. A mFI-5 score of ≥ 2 and a Nurick score of ≥ 3 defined frail and myelopathic patients, respectively. Univariate analysis (p<0.05) and multivariate analyses, using mixed-effect models, (p<0.0125), were performed. RESULTS: There were a total of 174 patients, 71 frail (41%). Of the frail patients, 61% were also myelopathic and 56% underwent ERAS. Of the non-frail patients, 43% were myelopathic and 57% underwent ERAS. On univariate analyses, frail patients with ERAS had less drains placed (p<0.0001), decreased urinary retention (p=0.0002), decreased LOS (p=0.013), and were less likely to have a non-home discharge (p=0.001). On multivariate analysis, LOS (p=0.0003), time to return of physiologic function (p=0.004), complications (p=0.001), and non-home discharges (p<0.0001) were decreased with ERAS, irrespective of groups. CONCLUSIONS: ERAS is an effective protocol in PCF patients that may expedite return of physiologic function, lessen LOS, decrease the number of non-home discharges, and reduce complications, irrespective of frailty or myelopathy status.

Oncolytic viral therapy: a review and promising future directions.

Oncolytic viral therapy is quickly emerging as a promising subset of immunotherapy, which theoretically can target tumor cells while sparing surrounding healthy cells by harnessing the replication machinery of viruses with tropism for tumor cells, resulting in direct oncolysis, and by transforming immunologically "cold" tumor into areas that elicit the host's immune response. This review provides an overview of oncolytic viral therapy until the present day, starting with the original concept in 1912. The general mechanism of oncolytic viruses (OVs) depends on selectively integrating them into tumor cells based on genetic engineering of viral genomic material, inducing oncolysis and eliciting the host's innate immune response. Moreover, a major component of oncolytic viral therapy has been herpes simplex virus, with talimogene laherparepvec being the only FDA-approved oncolytic viral therapy for the treatment of melanomas. This review explores the characteristics, advantages, disadvantages, and therapeutic uses of several DNA and RNA viral families. A snapshot of the oncolytic viral treatments used in the most recent and advanced clinical trials is also provided. Lastly, the challenges of implementing oncolytic viral therapy are explored, both at a molecular and clinical level, with a highlight of promising future directions. In particular, the lack of an optimal delivery method based on tumor type for oncolytic viral therapy poses a significant obstacle, even in clinical studies. Intrathecal continuous delivery of OVs is a promising prospect, potentially by adapting the novel continuous irrigation and drainage IRRAflow catheter. Further exploration and testing of the IRRAflow catheter should be undertaken.

The Safety and Efficacy of Concurrent Immune Checkpoint Blockade and Stereotactic Radiosurgery Therapy with Practitioner and Researcher Recommendations.

BACKGROUND: Immune checkpoint inhibitors (ICIs) have shown growing promise in the treatment of brain metastases, especially combined with stereotactic radiosurgery (SRS). The combination of ICIs with SRS has been studied for efficacy as well as increasing radiation necrosis risks. In this review, we compare clinical outcomes of radiation necrosis, intracranial control, and overall survival between patients with brain metastases treated with either SRS alone or SRS-ICI combination therapy. METHODS: A literature search of PubMed, Scopus, Embase, Web of Science, and Cochrane was performed in May 2023 for articles comparing the safety and efficacy of SRS/ICI versus SRS-alone for treating brain metastases. RESULTS: The search criteria identified 1961 articles, of which 48 met inclusion criteria. Combination therapy with SRS and ICI does not lead to significant increases in incidence of radiation necrosis either radiographically or symptomatically. Overall, no difference was found in intracranial control between SRS-alone and SRS-ICI combination therapy. Combination therapy is associated with increased median overall survival. Notably, some comparative studies observed decreased neurologic deaths, challenging presumptions that improved survival is due to greater systemic control. The literature supports SRS-ICI administration within 4 weeks of another for survival but remains inconclusive, requiring further study for other outcome measures. CONCLUSIONS: Combination SRS-ICI therapy is associated with significant overall survival benefit for patients with brain metastases without significantly increasing radiation necrosis risks compared to SRS alone. Although intracranial control rates appear to be similar between the 2 groups, timing of treatment delivery may improve control rates and demands further study attention.

Risk factors and outcomes associated with external ventricular drain related hemorrhage.

OBJECTIVE: The objective of this study was to determine risk factors predictive of external ventricular drain (EVD)-related hemorrhage and the association of such hemorrhages with mortality, discharge disposition, length of stay (LOS), and total cost. METHODS: After Institutional Review Board approval, data was collected retrospectively for adult patients requiring EVD placement from 2015 to 2018 at the authors' institution. Collected data included demographic patient information, peri-procedural factors, and relevant post-procedural measures. Computerized tomography (CT) images and associated radiologic reports were independently reviewed, identifying hemorrhages accompanying EVD placement. RESULTS: From this 487-patient sample, 85 (17.5 %) patients had hemorrhages, including asymptomatic hemorrhages identified on imaging alone. A univariable analysis of patient parameters in the overall cohort was performed to identify possible predictors of hemorrhage. Age (p = 0.002), Charlson Comorbidity Index (CCI) (p < 0.001), platelet count (p = 0.002), presence of uremia (p = 0.035), and the number of times the EVD was replaced (p < 0.001) were associated with hemorrhage in univariable models. The experience of the resident surgeon based on post-graduate year (PGY level) and the number of attempts/passes needed for EVD placement were not associated with hemorrhage risk. Significant predictor of hemorrhage confirmed in a multivariable analysis only included the number of times the EVD was replaced (OR = 2.78, adjusted p < 0.001). Outcomes between EVD-related hemorrhage versus no hemorrhage groups, including mortality, discharge disposition, LOS, and cost, were compared. EVD-related hemorrhage was found to be associated with increased mortality (OR = 3.58, adjusted p < 0.001) and decreased likelihood of discharge home (OR = 0.13, adjusted p = 0.030) in the associated multivariable regressions. CONCLUSION: The number of times an EVD was replaced was associated with EVD-related hemorrhage outcome. EVD-related hemorrhage is associated with increased mortality and a decreased likelihood of being discharged home.

Academic accomplishments of Black neurosurgeons in the United States.

OBJECTIVE: Neurosurgery has remained relatively homogeneous in terms of racial and gender diversity, trailing behind national demographics. Less than 5% of practicing neurosurgeons in the United States identify as Black/African American (AA). Research and academic productivity are highly emphasized within the field and are crucial for career advancement at academic institutions. They also serve as important avenues for mentorship and recruitment of diverse trainees and medical students. This study aimed to summarize the academic accomplishments of AA neurosurgeons by assessing publication quantity, h-index, and federal grant funding. METHODS: One hundred thirteen neurosurgery residency training programs accredited by the Accreditation Council for Graduate Medical Education in 2022 were included in this study. The American Society of Black Neurosurgeons registry was reviewed to analyze the academic metrics of self-identified Black or AA academic neurosurgeons. Data on the academic rank, leadership position, publication quantity, h-index, and race of neurosurgical faculty in the US were obtained from publicly available information and program websites. RESULTS: Fifty-five AA and 1393 non-AA neurosurgeons were identified. Sixty percent of AA neurosurgeons were fewer than 10 years out from residency training, compared to 37.4% of non-AA neurosurgeons (p = 0.001). AA neurosurgeons had a median 32 (IQR 9, 85) publications compared to 52 (IQR 22, 122) for non-AA neurosurgeons (p = 0.019). AA neurosurgeons had a median h-index of 12 (IQR 5, 24) compared to 16 (IQR 9, 31) for non-AA colleagues (p = 0.02). Following stratification by academic rank, these trends did not persist. No statistically significant differences in the median amounts of awarded National Institutes of Health funding (p = 0.194) or level of professorship attained (p = 0.07) were observed between the two cohorts. CONCLUSIONS: Racial disparities between AA and non-AA neurosurgeons exist in publication quantity and h-index overall but not when these groups are stratified by academic rank. Given that AA neurosurgeons comprise more junior faculty, it is expected that their academic accomplishments will increase as more enter academic practice and current neurosurgeons advance into more senior positions.

The Enhanced Recovery After Surgery pathway for posterior cervical surgery: a retrospective propensity-matched cohort study.

OBJECTIVE: The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery. METHODS: This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates. RESULTS: There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar. CONCLUSIONS: Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.

Subdural Pneumocephalus Aspiration Reduces Recurrence of Chronic Subdural Hematoma.

BACKGROUND: Chronic subdural hematoma (cSDH) is a common neurosurgical condition, with symptoms ranging from headaches to coma. Operative evacuation is the treatment of choice. Subdural reaccumulation leading to reoperation is a vexing postoperative complication. OBJECTIVE: To present a novel technique for intraoperative aspiration of pneumocephalus via a subdural drain following SDH evacuation as a method of reducing potential subdural space and promoting cerebral expansion, thereby decreasing SDH recurrence. METHODS: In this retrospective study, 15 patients who underwent operative evacuation of cSDH between 2008 and 2015 were assessed. Six patients underwent a small craniotomy with intraoperative pneumocephalus aspiration. These patients were matched by age, gender, and anticoagulation status to 9 patients who underwent evacuation of SDH without pneumocephalus aspiration. Quantitative volumetric analysis was performed on the preoperative, postoperative, and 1-mo follow-up computed tomography scan to assess the subdural volume. RESULTS: In the immediate postoperative period, there was no difference in the percentage of residual subdural fluid between the aspiration and control groups (0.291 vs 0.251; P = 1.00). There was a decrease in amount of pneumocephalus present when the aspiration technique was applied (0.182 vs 0.386; P = .041). At 1-mo follow-up, there was a decrease in the residual cSDH volume between the aspiration and the control groups (28.7 mL vs 60.8 mL; P = .011). The long-term evacuation rate was greater in the aspiration group (75.4% vs 51.6%; P = .015). CONCLUSION: Intraoperative aspiration of cSDH cavity is a safe technique that may enhance cerebral expansion and reduce likelihood of cSDH recurrence.

Variance Reduction in Neurosurgical Practice: The Case for Analytics-Driven Decision Support in the Era of Big Data.

OBJECTIVE: Variance between providers in neurosurgery can lead to inefficiencies and poor patient outcomes. Evidence-based guidelines (EBGs) have been developed; however, they have not been well implemented into the clinician workflow. Therefore, clinicians have been left to make decisions with incomplete information. Equally underused are the electronic health records (EHRs), which house enormous amounts of health data, but the power of that "big data" has failed to be capitalized on. METHODS: Early attempts at EBGs were rigid and nonadaptive; however, with the current advances in data informatics and machine learning algorithms, it is now possible to integrate "big data" and rapid data processing into clinical decision support tools. We have presented an overview of the background of EHRs and EBGs in neurosurgery and explored the possibility of integrating them to reduce unwanted variance. RESULTS: As we strive toward variance reduction in healthcare, the integration of "big data" and EBGs for decision-making will be key. We have proposed that EHRs are an ideal platform for integrating EBGs into the clinician workflow and have presented as an example of a successful early generation model, Neurocore. With this approach, it will be possible to build EBGs into the EHR software, to continuously update and optimize EBGs according to the flow of patient data into the EHR, and to present data-driven clinical decision support at the point of care. CONCLUSIONS: Variance reduction in neurosurgery through the integration of evidence-based decision support in EHRs will lead to improved patient safety, a reduction in medical errors, maximization of the use of the available data, and enhanced decision-making power for clinicians.

Transitional care services: a quality and safety process improvement program in neurosurgery.

OBJECTIVE Readmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. However, few readmission reduction programs have targeted surgical patient populations. The objective of this study was to establish a transitional care program (TCP) with the goal of decreasing length of stay (LOS), improving discharge efficiency, and reducing readmissions of neurosurgical patients by optimizing patient education and postdischarge surveillance. METHODS Patients undergoing elective cranial or spinal neurosurgery performed by one of 5 participating surgeons at a quaternary care hospital were enrolled into a multifaceted intervention. A preadmission overview and establishment of an anticipated discharge date were both intended to set patient expectations for a shorter hospitalization. At discharge, in-hospital prescription filling was provided to facilitate medication compliance. Extended discharge appointments with a neurosurgery TCP-trained nurse emphasized postoperative activity, medications, incisional care, nutrition, signs that merit return to medical attention, and follow-up appointments. Finally, patients received a surveillance phone call 48 hours after discharge. Eligible patients omitted due to staff limitations were selected as controls. Patients were matched by sex, age, and operation type-key confounding variables-with control patients, who were eligible patients treated at the same time period but not enrolled in the TCP due to staff limitation. Multivariable logistic regression evaluated the association of TCP enrollment with discharge time and readmission, and linear regression with LOS. Covariates included matching criteria and Charlson Comorbidity Index scores. RESULTS Between 2013 and 2015, 416 patients were enrolled in the program and matched to a control. The median patient age was 55 years (interquartile range 44.5-65 years); 58.4% were male. The majority of enrolled patients underwent spine surgery (59.4%, compared with 40.6% undergoing cranial surgery). Hospitalizations averaged 62.1 hours for TCP patients versus 79.6 hours for controls (a 16.40% reduction, 95% CI 9.30%-23.49%; p < 0.001). The intervention was associated with a higher proportion of morning discharges, which was intended to free beds for afternoon admissions and improve patient flow (OR 3.13, 95% CI 2.27-4.30; p < 0.001), and decreased 30-day readmissions (2.5% vs 5.8%; OR 2.43, 95% CI 1.14-5.27; p = 0.02). CONCLUSIONS This neurosurgical TCP was associated with a significantly shorter LOS, earlier discharge, and reduced 30-day readmission after elective neurosurgery. These results underscore the importance of patient education and surveillance after hospital discharge.

International practice variation in postoperative imaging of chronic subdural hematoma patients.

OBJECTIVE: The value of CT scanning after burr hole surgery in chronic subdural hematoma (CSDH) patients is unclear, and practice differs between countries. At the Brigham and Women's Hospital (BWH) in Boston, Massachusetts, neurosurgeons frequently order routine postoperative CT scans, while the University Medical Center Utrecht (UMCU) in the Netherlands does not have this policy. The aim of this study was to compare the use of postoperative CT scans in CSDH patients between these hospitals and to evaluate whether there are differences in clinical outcomes. METHODS: The authors collected data from both centers for 391 age- and sex-matched CSDH patients treated with burr hole surgery between January 1, 2002, and July 1, 2016, and compared the number of postoperative scans up to 6 weeks after surgery, the need for re-intervention, and postoperative neurological condition. RESULTS: BWH patients were postoperatively scanned a median of 4 times (interquartile range [IQR] 2-5), whereas UMCU patients underwent a median of 0 scans (IQR 0-1, p < 0.001). There was no significant difference in the number of re-operations (20 in the BWH vs 27 in the UMCU, p = 0.34). All re-interventions were preceded by clinical decline and no recurrences were detected on scans performed on asymptomatic patients. Patients' neurological condition was not worse in the UMCU than in the BWH (p = 0.43). CONCLUSIONS: While BWH patients underwent more scans than UMCU patients, there were no differences in clinical outcomes. The results of this study suggest that there is little benefit to routine scanning in asymptomatic patients who have undergone surgical treatment of uncomplicated CSDH and highlight opportunities to make practice more efficient.

Insular infarction in subdural hematoma: A case series and pathophysiologic review.

Subdural hematoma (SDH) is among the most common conditions managed by neurologists and neurosurgeons. As SDH incidence rates increase, a wider spectrum of SDH related complications have become evident. We prospectively identified a series of three patients with similar patterns of ipsilateral insular diffusion weighted imaging (DWI) hyperintensity associated with subdural hematoma. Detailed chart review was performed, and cases are described in relation to anatomy and proposed pathophysiology of venous hypertension and arterial vasospasm. The DWI changes were evident in all cases where clinical deficits following SDH evacuation were out of proportion to computed tomography findings. Therefore SDH-associated insular infarction may be a marker of greater disease severity, and further study of management and outcomes is needed.

Defensive Medicine in U.S. Spine Neurosurgery.

STUDY DESIGN: Observational cross-sectional survey. OBJECTIVE: To compare defensive practices of U.S. spine and nonspine neurosurgeons in the context of state medical liability risk. SUMMARY OF BACKGROUND DATA: Defensive medicine is a commonly reported and costly phenomenon in neurosurgery. Although state liability risk is thought to contribute greatly to defensive practice, variation within neurosurgical specialties has not been well explored. METHODS: A validated, online survey was sent via email to 3344 members of the American Board of Neurological Surgeons. The instrument contained eight question domains: surgeon characteristics, patient characteristics, practice type, insurance type, surgeon liability profile, basic surgeon reimbursement, surgeon perceptions of medical legal environment, and the practice of defensive medicine. RESULTS: The overall response rate was 30.6% (n = 1026), including 499 neurosurgeons performing mainly spine procedures (48.6%). Spine neurosurgeons had a similar average practice duration as nonspine neurosurgeons (16.6 vs 16.9 years, P = 0.64) and comparable lifetime case volume (4767 vs 4,703, P = 0.71). The average annual malpractice premium for spine neurosurgeons was similar to nonspine neurosurgeons ($104,480.52 vs $101,721.76, P = 0.60). On average, spine neurosurgeons had a significantly higher rate of ordering labs, medications, referrals, procedures, and imaging solely for liability concerns compared with nonspine neurosurgeons (89.2% vs 84.6%, P = 0.031). Multivariate analysis revealed that spine neurosurgeons were roughly 3 times more likely to practice defensively compared with nonspine neurosurgeons (odds ratio, OR = 2.9, P = 0.001) when controlling for high-risk procedures (OR = 7.8, P < 0.001), annual malpractice premium (OR = 3.3, P = 0.01), percentage of patients publicly insured (OR = 1.1, P = 0.80), malpractice claims in the last 3 years (OR = 1.13, P = 0.71), and state medical-legal environment (OR = 1.3, P = 0.37). CONCLUSION: State-based medical legal environment is not a significant driver of increased defensive medicine associated with neurosurgical spine procedures. LEVEL OF EVIDENCE: 3.

Current Strategies in the Surgical Management of Ischemic Stroke.

Stroke is a major cause of death and disability in the United States and rapid evaluation and treatment of stroke patients are critical to good outcomes. Effective surgical treatments aim to restore adequate cerebral blood flow, prevent secondary brain injury, or reduce the likelihood of recurrent stroke. Patient evaluation in centers with a comprehensive stroke program and a dedicated neuro- vascular team is recommended. [Full article available at http://rimed.org/rimedicaljournal-2017-06.asp].

The impact of aspirin and anticoagulant usage on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis.

OBJECTIVE Although aspirin usage may be associated with a decreased risk of rupture of cerebral aneurysms, any potential therapeutic benefit from aspirin must be weighed against the theoretical risk of greater hemorrhage volume if subarachnoid hemorrhage (SAH) occurs. However, few studies have evaluated the association between prehemorrhage aspirin use and outcomes. This is the first nationwide analysis to evaluate the impact of long-term aspirin and anticoagulant use on outcomes after SAH. METHODS Data from the Nationwide Inpatient Sample (NIS; 2006-2011) were extracted. Patients with a primary diagnosis of SAH who underwent microsurgical or endovascular aneurysm repair were included; those with a diagnosis of an arteriovenous malformation were excluded. Multivariable logistic regression was performed to calculate the adjusted odds of in-hospital mortality, a nonroutine discharge (any discharge other than to home), or a poor outcome (death, discharge to institutional care, tracheostomy, or gastrostomy) for patients with long-term aspirin or anticoagulant use. Multivariable linear regression was used to evaluate length of hospital stay. Covariates included patient age, sex, comorbidities, primary payer, NIS-SAH severity scale, intracerebral hemorrhage, cerebral edema, herniation, modality of aneurysm repair, hospital bed size, and whether the hospital was a teaching hospital. Subgroup analyses exclusively evaluated patients treated surgically or endovascularly. RESULTS The study examined 11,549 hospital admissions. Both aspirin (2.1%, n = 245) and anticoagulant users (0.9%, n = 108) were significantly older and had a greater burden of comorbid disease (p < 0.001); severity of SAH was slightly lower in those with long-term aspirin use (p = 0.03). Neither in-hospital mortality (13.5% vs 12.6%) nor total complication rates (79.6% vs 80.0%) differed significantly by long-term aspirin use. Additionally, aspirin use was associated with decreased odds of a cardiac complication (OR 0.57, 95% CI 0.36%-0.91%, p = 0.02) or of venous thromboembolic events (OR 0.53, 95% CI 0.30%-0.94%, p = 0.03). Length of stay was significantly shorter (15 days vs 17 days [12.73%], 95% CI 5.22%-20.24%, p = 0.001), and the odds of a nonroutine discharge were lower (OR 0.63, 95% CI 0.48%-0.83%, p = 0.001) for aspirin users. In subgroup analyses, the benefits of aspirin were primarily noted in patients who underwent coil embolization; likewise, among patients treated endovascularly, the adjusted odds of a poor outcome were lower among long-term aspirin users (31.8% vs 37.4%, OR 0.63, 95% CI 0.42%-0.94%, p = 0.03). Although the crude rates of in-hospital mortality (19.4% vs 12.6%) and poor outcome (53.6% vs 37.6%) were higher for long-term anticoagulant users, in multivariable logistic regression models these variations were not significantly different (mortality: OR 1.36, 95% CI 0.89%-2.07%, p = 0.16; poor outcome: OR 1.09, 95% CI 0.69%-1.73%, p = 0.72). CONCLUSIONS In this nationwide study, neither long-term aspirin nor anticoagulant use were associated with differential mortality or complication rates after SAH. Aspirin use was associated with a shorter hospital stay and lower rates of nonroutine discharge, with these benefits primarily observed in patients treated endovascularly.

Unplanned Reoperation After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: Reoperation has been increasingly utilized as a metric evaluating quality of care. OBJECTIVE: To evaluate the rate of, reasons for, and predictors of unplanned reoperation after craniotomy for tumor in a nationally accrued population. METHODS: Patients who underwent cranial tumor resection were extracted from the prospective National Surgical Quality Improvement Program registry (2012-2014). Multivariate logistic regression examined predictors of unplanned cranial reoperation. Predictors screened included patient age, sex, tumor location and histology, functional status, comorbidities, preoperative laboratory values, operative urgency, and time. RESULTS: Of the 11 462 patients included, 3.1% (n = 350) underwent an unplanned cranial reoperation. The most common reasons for cranial reoperation were intracranial hematoma evacuation (22.5%), superficial or intracranial surgical site infections (11.9%), re-resection of tumor (8.4%), decompressive craniectomy (6.1%), and repair of cerebrospinal fluid leakage (5.6%). The strongest predictor of any cranial reoperation was preoperative thrombocytopenia (less than 100 000/µL, odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.23-5.10, P = .01). Thrombocytopenia, hypertension, emergent surgery, and longer operative time were predictors of reoperation for hematoma (P ≤ .004), while dependent functional status, morbid obesity, leukocytosis, and longer operative time were predictors of reoperation for infection (P < .05). Although any unplanned cranial reoperation was not associated with differential odds of mortality (OR = 1.68, 95% CI: 0.94-3.00, P = .08), hematoma evacuation was significantly associated with thirty-day death (P = .04). CONCLUSION: In this national analysis, unplanned cranial reoperation was primarily associated with operative indices, rather than preoperative characteristics, suggesting that reoperation may have some utility as a quality indicator. However, hypertension and thrombocytopenia were potentially modifiable predictors of reoperation.

Readmission After Craniotomy for Tumor: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: Although readmission has become a common quality indicator, few national studies have examined this metric in patients undergoing cranial surgery. OBJECTIVE: To utilize the prospective National Surgical Quality Improvement Program 2011-2013 registry to evaluate the predictors of unplanned 30-d readmission and postdischarge mortality after cranial tumor resection. METHODS: Multivariable logistic regression was applied to screen predictors, which included patient age, sex, tumor location and histology, American Society of Anesthesiologists class, functional status, comorbidities, and complications from the index hospitalization. RESULTS: Of the 9565 patients included, 10.7% (n = 1026) had an unplanned readmission. Independent predictors of unplanned readmission were male sex, infratentorial location, American Society of Anesthesiologists class 3 designation, dependent functional status, a bleeding disorder, and morbid obesity (all P ≤ .03). Readmission was not associated with operative time, length of hospitalization, discharge disposition, or complications from the index admission. The most common reasons for readmission were surgical site infections (17.0%), infectious complications (11.0%), venous thromboembolism (10.0%), and seizures (9.4%). The 30-d mortality rate was 3.2% (n = 367), of which the majority (69.7%, n = 223) occurred postdischarge. Independent predictors of postdischarge mortality were greater age, metastatic histology, dependent functional status, hypertension, discharge to institutional care, and postdischarge neurological or cardiopulmonary complications (all P < .05). CONCLUSION: Readmissions were common after cranial tumor resection and often attributable to new postdischarge complications rather than exacerbations of complications from the initial hospitalization. Moreover, the majority of 30-d deaths occurred after discharge from the index hospitalization. The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization management.