Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training.

OBJECTIVE: Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity. METHODS: Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey. RESULTS: A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models. CONCLUSIONS: The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.

Palliative Care Effects on Survival in Glioblastoma: Who Receives Palliative Care?

BACKGROUND: High-grade glioma has a poor overall survival with profoundly negative effects on the patient's quality of life and their caregivers. In this study, we investigate the factors associated with receiving palliative care in patients diagnosed with glioblastoma (GBM) and the association of receiving or not receiving palliative care with overall survival. METHODS: The National Cancer Database was analyzed for patterns of care in patients ≥18 years old who were diagnosed with histologically confirmed grade IV GBM between 2004 and 2017. All statistical analyses were conducted based on univariate and multivariate regression models. RESULTS: A total of 85,380 patients with the diagnosis of GBM were identified. Of the study population, 2803 patients (3.28%) received palliative therapy. On multivariate logistic regression analysis, age ≥70 years (odds ratio [OR], 1.28; 95% confidence interval [CI], 1.04-1.58; P < 0.001), Medicare (OR, 1.348; CI, 1.13-1.61; P = 0.001), tumor size ≥5 cm (OR, 1.15; CI, 1.01-1.31; P = 0.036), tumor multifocality (OR, 1.69; CI, 1.47-1.96; P < 0.001), lobe overlapping tumor (OR, 2.09; CI, 1.13-3.86; P = 0.018), Charlson-Deyo score >0, receiving treatment at a nonacademic/research program, and medium volume of cancers managed at the treatment facility (OR, 1.19; CI, 1.02-1.38; P = 0.026) were independent risk factors associated with an increased chance of receiving palliative care. In contrast, a household income of ≥$40,227 and high volume of cancer managed at the treatment facility (OR, 0.75; CI, 0.58-0.96; P = 0.02) were independent risk factors associated with decreased palliative care. Patients who received no palliative care had a 2-year overall survival longer than those who received palliative care (22% vs. 8.8%; P < 0.001). In patients receiving palliative care, those who received recommended treatment had a 2-year overall survival longer than those who declined part or whole recommended treatment (9.1% vs. 3.8%; P = 0.009). CONCLUSIONS: In patients with high-grade glioma, receiving palliative care is associated with decreased survival. When receiving palliative care, recommended treatment increases the number of patients who survive more than 2 years approximately 3-fold compared with those declining part or whole treatment.

Patient satisfaction and cost savings analysis of the telemedicine program within a neuro-oncology department.

PURPOSE: Unique challenges exist in the utilization of telemedicine for neurological and surgical specialties. We examined the differences in patient satisfaction for telemedicine versus in-person visits within a Neuro-Oncology Program to assess whether there was a difference between surgical and medical specialties. We also examined the potential cost savings benefits of utilizing telemedicine. METHODS: 1189 Press Ganey surveys in the Department of Neuro-Oncology (982 in-person and 207 telemedicine) by surgical and medical neuro-oncology patients between 04/01/2020 and 06/30/2021 were reviewed. Survey results were divided into 4 categories (Access, Provider, Technology (telemedicine only), and Overall Satisfaction). Results were analyzed for the impact of telemedicine versus in-person visits, and gender, age, insurance, and specialty. Cost savings were calculated based on potential travel distance and lost productivity. RESULTS: Survey results from telemedicine visits demonstrated that patients with private insurance returned higher scores in the Provider (p = 0.0089), Technology (p = 0.00187), and Overall (p = 0.00382) categories. Surgical patients returned higher scores for Access (p = 0.0015), Technology (p = 0.0002), and Overall (p = 0.0019). When comparing telemedicine to in-person scores, in-person scored higher in Provider (p = 0.0092) for all patients, while in-person scored higher in Access (p = 0.0252) amongst surgical patients. Cost analysis revealed that telemedicine allowed patients to save an average of 4.1 to 5.6 h per visit time and a potential cost savings of up to $223.3 ± 171.4. CONCLUSION: Telemedicine yields equivalent patient satisfaction when employed in surgical as compared to medical Neuro-Oncology patients with the potential to lessen the financial and time burden on neuro-oncology patients.

Development and Validation of a Low-Cost Endoscopic Spine Surgery Simulator.

Background Minimally invasive endoscopic techniques in spine surgery continue to gain in popularity. Unfortunately, there is a long learning period for novice endoscope users to acquire basic skills, and complex training simulators are frequently cost-prohibitive. This paper describes the development and validation of a low-cost endoscopic spine training simulator. Methodology A low-cost endoscopic spine training model was created utilizing a budget of less than 65 USD. Afterward, a training curriculum consisting of five tasks was designed to mimic standard techniques frequently utilized in endoscopic spine surgery. This curriculum was tested on a cohort of surgical trainees. The initial time to completion as well as errors made during the tasks and repeat trials were recorded. A composite score was generated to quantify the overall scores which included both time and errors in each task. Results In total, 11 students and surgical residents completed the curriculum. The first attempt required an average of 622 seconds for the completion of the curriculum compared to 283 seconds in the second trial (p < 0.001; SD = 36.75). In regards to trials in which errors were counted, fewer errors occurred during the second attempt (2.55 vs. 1.53); however, this difference was not statistically significant (p > 0.05). In regards to the composite score, the composite score of the intern group demonstrated an average improvement of 0.345 compared to an average improvement of 0.47 in the resident group. Conclusions Our study demonstrates the feasibility of a low-cost endoscopic spine trainer as well as its efficacy in improving basic endoscopic skills in trainees.

Impact of Diabetes Mellitus on Adverse Outcomes After Meningioma Surgery.

OBJECTIVE: We sought to investigate the association between diabetes mellitus and incidence of adverse outcomes in patients who underwent meningioma surgery. METHODS: The 2012-2014 National Inpatient Sample database was used. Prolonged length of stay was indicated by values greater than the 90th percentile of the sample. The Fisher exact test and analysis of variance were used to compare demographics, hospital characteristics, comorbidity, and complications among race cohorts. Logistic regression was used to analyze the independent effect of diabetes on adverse outcomes. RESULTS: After selecting for patients with primary diagnosis of meningioma who underwent a resection procedure, 7745 individuals were identified and divided into diabetic (n = 1518) and nondiabetic (n = 6227) cohorts. Demographics, hospital characteristics, and comorbidities were significantly different among the 2 cohorts. Average length of stay was longer in diabetic patients (8.15 vs. 6.04 days, P < 0.001), and total charges were higher in diabetic patients ($139,462.66 vs. $123,250.71, P < 0.001). Multivariate regression indicated diabetic patients have higher odds of experiencing a complication (odds ratio [OR] 1.442, 95% confidence interval [CI] 1.255-1.656, P < 0.001) and in-hospital mortality (OR 1.672, 95% CI 1.034-2.705, P = 0.036) after meningioma surgery. Analysis of individual postoperative complications revealed that diabetic patients experienced increased odds of pulmonary (OR 1.501, 95% CI 1.209-1.864, P < 0.001), neurologic (OR 1.690, 95% CI 1.383-2.065, P < 0.001), and urinary/renal complications (OR 2.618, 95% CI 1.933-3.545, P < 0.001). In addition, diabetic patients were more likely to have a prolonged length of stay (OR 1.694, 95% CI 1.389-2.065, P < 0.001). CONCLUSIONS: Diabetes is an important factor associated with complications after meningioma surgery. Preventative measures must be taken to optimize postoperative outcomes in these patients.

Gender differences in NIH grant funding in neurological surgery.

Research productivity is a vital component to an academic neurosurgeon's career. We sought to evaluate gender differences in NIH funding among faculty in neurological surgery departments. NIH funding awarded to PIs of neurological surgery departments from 2014 to 2019 were obtained and analyzed for gender differences in funding trends, with attention to terminal degree and academic rank, as well as publication range in length of years and h-index. 79.4% of all NIH grants were awarded to male PIs, with the remaining 20.5% given to their female counterparts. Mean of the total NIH grants awarded to men was significantly higher at $1,796,684 (± Standard Error of Mean (SEM) $155,849, IQR: $1,759,250) compared to women at $1,151,968 (± SEM $137,914, IQR: $1,388,538) (P = 0.022). Mean NIH funding per grant for men was $365,760 (± SEM: $39,592, IQR: $189,692) and for women was $292,912 (± SEM: 28,239, IQR: $283,177). Differences in mean NIH funding per grant approached but did not reach statistical significance between men and women (P = 0.122). When stratified for academic rank, there was a significant difference in mean NIH funding per grant between men and women on the associate professor level (p < 0.005), with women exceeding men in funding at this academic level, with other academic ranks remaining non-significant. Overall, male neurosurgeons receive significantly more total NIH grant funding than their female counterparts, except at the level of associate professor where women were found to surpass men.

Changing trends in management of vestibular schwannoma: A National Cancer Database study.

OBJECTIVE: To describe changes in management trends of vestibular schwannoma (VS) and the effects of median income, education level, insurance status, and tumor size on receipt of treatment. METHODS: Cross-sectional analysis using the National Cancer Database from 2004 to 2014. All patients with a diagnosis of VS were identified between 2004 and 2014. Trends in treatment modality over time were analyzed. Correlation between demographics, institution type, median income, education level, and insurance status were assessed using univariate and multivariate logistic regressions. RESULTS: Of the 22,290 VS patients identified, 16,011 (71.8%) received treatment, whereas 6,279 (28.2%) received observation. Management trend analysis over the 11-year period revealed patients with tumor size < 1 cm are more frequently observed (34.6% of cases in 2004 vs. 60.8% of cases in 2014) and less frequently received surgery (34.6% vs. 16.8%). Multivariate analysis showed observation was more frequently used in patients ≥ 65 years; black patients; and those on Medicaid, Medicare, and noninsured (P < 0.0001). All tumors > 2 cm were more likely to be treated with surgery, specifically subtotal resections (P < 0.0001). Patients treated at nonacademic centers were more likely to receive linear accelerator, or LINAC (Accuray Incorporated, Sunnyvale, CA) therapy than Gamma Knife (Elekta, Stockholm, Sweden) (P < 0.0001). CONCLUSION: Management of VS is shifting toward increased observation, most significantly in tumors size < 1 cm. Insurance provider plays a significant role on receipt of treatment and modality, whereas income and education do not. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1197-1205, 2019.

Impact of venous thromboembolism during admission for meningioma surgery on hospital charges and postoperative complications.

Surgical resection of meningiomas has been associated with high rates of venous thromboembolic events (VTE) as compared with all other intracranial tumors. There is a paucity of data regarding the clinical complications and comorbidities associated with this cohort yet the underlying pathophysiological mechanism for this tumor-specific finding remains unclear. Our goal was to determine the various impacts of VTE on meningioma surgery in a large cohort of inpatient admissions. This retrospective analysis utilized discharge data from the National Inpatient Sample (NIS) from 2002 to 2010. Patient demographics, comorbidities, length of stay, hospital charges, and postoperative complications were compared between patients with and without VTE. Of 20,259 patients, 426 (2.1%) experienced a VTE. Compared to the non-VTE cohort, patients that experienced a VTE were older (62.7 ±â€¯13.7 vs. 57.2 ±â€¯14.7; p < 0.001), were more commonly male (38.0% vs 30.1%; p = 0.001), had longer hospitalizations (18.8 vs 6.6 days; p < 0.001), and incurred significantly greater hospital charges ($195,837 vs $74,434; p < 0.001). VTE patients experienced significantly higher rates of acute postoperative complications including shock, hemorrhage, wound dehiscence, infection, intracerebral hemorrhage, hemiparesis/hemiplegia, stroke, and death during admission. Odds ratio of aforementioned postsurgical complications remained significantly higher both before and after adjusting for age and sex (all p < 0.01). Occurrence of VTE in patients undergoing meningioma resection portends greater hospital charges, most likely attributed to longer lengths of admission. Increased postoperative complications and mortality in the VTE group warrants further investigation and wariness of the surgeon when treating surgical candidates of meningioma.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center.

BACKGROUND: Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population. METHODS: We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia. CONCLUSION: Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

The Impact of Resident and Fellow Participation in Transsphenoidal Pituitary Surgery.

OBJECTIVES/HYPOTHESIS: Postoperative complications is an important marker of healthcare quality. The aim of this study was to analyze the impact of resident and fellow participation on postoperative complications in transsphenoidal pituitary surgery in a multi-institutional setting. STUDY DESIGN: Retrospective analysis of population-based surgical registry. SETTING: Academic medical center. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was utilized to generate transsphenoidal pituitary surgery patient cohorts. The attending with resident and/or fellow group was compared to the attending alone based on demographics and preoperative and postoperative variables. RESULTS: A total of 469 cases were included in the analysis, with 315 performed with resident participation and 154 by attendings alone. The attending group had higher rates of diabetics (20.1% vs. 11.7%, P = 0.015) and patients with a history of previous percutaneous coronary intervention (6.0 vs. 1.6%, P = 0.009). Although the attending group demonstrated higher rates of surgical complications, and the resident/fellow group showed increased incidence in medical and overall complication rates, there was no statistical difference between the two groups. Multivariate analysis further demonstrated lack of significance in complication rates between attendings and residents/fellows. CONCLUSION: Resident and fellow participation in transsphenoidal surgery is not associated with significant differences in surgical complications, medical complications, mortality, operating time, reoperation rates, or readmission rates when compared to attendings. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2707-2713, 2018.

Examining the "July effect" on patients undergoing pituitary surgery.

BACKGROUND: Our aim in this study was to assess the impact of the turnover of residents in July on patients undergoing pituitary surgery. METHODS: This work was a retrospective cohort study of cases from the National Inpatient Sample (NIS). Patients who underwent pituitary surgery from 2005 to 2012 were selected in the NIS. Patients undergoing surgery in July and in non-July months were compared to determine differences in demographics, comorbidities, and complications. RESULTS: Of the 12,939 patients, 1098 (8.5%) underwent pituitary surgery in July. Patients receiving surgery in July had similar demographics and Agency for Healthcare Research and Quality comorbidity values compared with patients receiving surgery in other months. There were no significant differences in mortality, cerebral edema, cerebrospinal fluid leakage, iatrogenic pituitary complications, iatrogenic cerebrovascular accidents, urinary tract infections, pulmonary edema, pulmonary complications, or acute cardiac complications. There were no differences in the rate of postoperative fistulas, hematomas, perforations, or infections. The use of meningeal suturing, pedicled or free-flap reconstruction, and skin reconstruction was more frequent in July. Finally, hospitalization costs in July were similar to costs in other months. CONCLUSION: The turnover of new residents in July showed no change in complication rates for patients undergoing pituitary surgery. Patient care in July is similar to care during other months, demonstrating that hospitals are adequately supervising surgical residents during this transition.

The Role of Fast Imaging Employing Steady-State Acquisition (FIESTA) Magnetic Resonance Imaging for Assessment of Delayed Enhancement of Fat Graft Packing on Postoperative Imaging After Vestibular Schwannoma Surgery.

OBJECTIVE: To investigate the role and efficacy of fast imaging employing steady-state acquisition (FIESTA) imaging in distinguishing fat graft enhancement from residual or recurrent tumor after vestibular schwannoma (VS) surgery. METHODS: A retrospective study of 33 patients who underwent VS resection via the retrosigmoid or translabyrinthine approach with fat graft reconstruction was performed. Magnetic resonance imaging (MRI) was collected at different time points: preoperative, immediate postoperative (24-48 hours), delayed postoperative (3-6 months after surgery), and yearly postoperative. The image sets contained T1, T2, fat-suppressed T1-weighted with gadolinium, and FIESTA. The radiographs were analyzed for tumor recurrence by the primary neurosurgeon and an independent blinded neuroradiologist. If fat-suppressed T1-weighted images demonstrated postoperative enhancement in the resection bed, a comparison was made with FIESTA imaging. RESULTS: At 3-6 months postoperatively and at 1 year and beyond, 28 (84.8%) and 33 (100%) of patients, respectively, displayed delayed enhancement of the fat graft on postgadolinium fat-suppressed T1-weighted MRI. The enhancement seen on postgadolinium, fat-suppressed, T1-weighted MRI consistently correlated with the characteristic fat graft signal on FIESTA imaging and not tumor recurrence. FIESTA imaging was able to distinguish residual tumor from enhancing fat graft compared with postgadolinium, fat-suppressed, T1-weighted MRI (P < 0.0001) due to distinctive signaling patterns. CONCLUSIONS: FIESTA is an effective tool in discerning fat graft enhancement from residual or recurrent tumor on delayed postoperative imaging after VS resection. Fat graft used in reconstruction consistently enhances on delayed postoperative postgadolinium, fat-suppressed, T1-weighted imaging, which correlates with the fat graft signal seen on FIESTA images.

Pituitary and skull-base lesions and the litigious patient.

BACKGROUND: The objective of this research was to evaluate litigation relating to the diagnosis and management of pituitary and ventral skull base lesions and delineate allegations involved in the decision to pursue medicolegal proceedings. METHODS: Publically available federal and court records were accessed via the Westlaw Next database. Jury verdict and settlement reports relevant to pituitary and anterior skull-base lesions were accessed, and litigation was reviewed for alleged injuries, defendant specialty, patient demographics, and other factors raised in proceedings. RESULTS: Of 75 cases included, 50.7% were resolved in the defendant's favor. The most frequent physician specialties cited as defendants included primary care (20%), neurosurgery (17%), and radiology (16%), while otolaryngologists were defendants in only 5% of cases. Fifty-two (69%) did not involve surgical intervention; the most common allegations in these proceedings were misdiagnosis, permanent injury (19%), requiring additional procedures as a result of misdiagnosis (17%), permanent endocrine dysfunction (14%), and visual sequelae (12%). Among surgical cases, the most common allegations raised included permanent injury (17%), postoperative complications (14%), intraoperative complications (13%), and death (10%). Among cases resolved with payment, there was no statistical difference in payment between surgical cases ($5.7M) and nonsurgical cases ($4.8M). CONCLUSION: Misdiagnosis of endocrinopathy, failure to appropriately workup patients presenting with neurologic complaints, and radiologic misdiagnosis play important roles in the pursuit of litigation in nonsurgical cases. Sustaining permanent sequelae including endocrine and visual injury play an important role in surgical cases. Postoperative management appears to play just as important a role in the decision to pursue litigation as intraoperative considerations.

Is Industry Funding Associated with Greater Scholarly Impact Among Academic Neurosurgeons?

OBJECTIVE: To determine the relationship between industry payments and scholarly impact among academic neurosurgeons. METHODS: Faculty names and academic rank data were obtained from department websites, bibliometric data were obtained from the Scopus database, and industry payment data were obtained from the Center for Medicare and Medicaid Services open payments database (openpayments.cms.gov). The h-index was used to estimate scholarly impact. Payments were classified as "general," "associated research," and "research payments." Subgroup analyses were done for academic rank, fellowship training, and sex. RESULTS: Among 1008 academic neurosurgeons, scholarly impact was greater among individuals receiving associated research industry support compared with those not receiving it. Scholarly impact also was greater among individuals who received more than $10,000 of any type of industry support compared with individuals who received less than that or no payment. This association also was seen in fellowship-trained surgeons. Female neurosurgeons were less likely than male neurosurgeons to get industry funding and were likely to get less funding. CONCLUSIONS: There is a strong association between associated research funding from industry and scholarly impact among academic neurosurgeons. It's unclear whether this association is a result of funding facilitating more research projects that eventually lead to more high-impact publications, if industry is providing more funding to academic neurosurgeons with greater scholarly impact, or whether it represents intrinsic academic activity among a group of neurosurgeons who are more likely to be academically productive and procure funding from all potential sources to increase this activity.

Lower airway disease and pituitary surgery: Is there an association with postoperative cerebrospinal fluid leak?

OBJECTIVES/HYPOTHESIS: To explore the relationship between lower airway disease and postoperative cerebrospinal fluid (CSF) rhinorrhea among patients undergoing pituitary surgery STUDY DESIGN: Retrospective review. METHODS: A retrospective review of the Healthcare Cost and Utilization Project's 2013 National Inpatient Sample was conducted to characterize the hospital stay and surgical outcomes of patients undergoing pituitary surgery. Patients with lower airway disease (including chronic obstructive pulmonary disease and asthma) were compared to a disease-free population identifying demographics and complications over-represented in the lower airway group. RESULTS: The majority of hypophysectomies (92.1%) were performed via a transsphenoidal approach. Among transsphenoidal patients, individuals with asthma (92.8% of the lower airway disease cohort) harbored a greater postoperative CSF leak rate (4.7% vs. 2.7%, P = .022), and were more likely to develop postoperative diabetes insipidus (6.2% vs. 4.1%, P = .024) and neurological complications (13.0% vs. 9.6%, P = .010) when compared to a lower airway disease-free cohort. Patients with CSF rhinorrhea had longer lengths of stay (7.8 days vs. 4.5 days, P < .001) and higher discharge costs ($148,309 vs. $76,246, P < .001). A binary logistic regression model identified having asthma (P = .042), being female (P = .011), and having gastroesophageal reflux disease (P = .006) as independent predictors of postoperative CSF rhinorrhea. CONCLUSIONS: Several patient comorbidities including asthma are associated with a greater risk of postoperative CSF rhinorrhea. Perioperative lower airway assessment and disease control may potentially decrease one's risk of this complication, although further inquiry is urgently needed to identify optimal preventive strategies. LEVEL OF EVIDENCE: 2c. Laryngoscope, 127:1543-1550, 2017.

Cost-Effectiveness Analysis of Microscopic and Endoscopic Transsphenoidal Surgery Versus Medical Therapy in the Management of Microprolactinoma in the United States.

BACKGROUND: Although prolactinomas are treated effectively with dopamine agonists, some have proposed curative surgical resection for select cases of microprolactinomas to avoid life-long medical therapy. We performed a cost-effectiveness analysis comparing transsphenoidal surgery (either microsurgical or endoscopic) and medical therapy (either bromocriptine or cabergoline) with decision analysis modeling. METHODS: A 2-armed decision tree was created with TreeAge Pro Suite 2012 to compare upfront transsphenoidal surgery versus medical therapy. The economic perspective was that of the health care third-party payer. On the basis of a literature review, we assigned plausible distributions for costs and utilities to each potential outcome, taking into account medical and surgical costs and complications. Base-case analysis, sensitivity analysis, and Monte Carlo simulations were performed to determine the cost-effectiveness of each strategy at 5-year and 10-year time horizons. RESULTS: In the base-case scenario, microscopic transsphenoidal surgery was the most cost-effective option at 5 years from the time of diagnosis; however, by the 10-year time horizon, endoscopic transsphenoidal surgery became the most cost-effective option. At both time horizons, medical therapy (both bromocriptine and cabergoline) were found to be more costly and less effective than transsphenoidal surgery (i.e., the medical arm was dominated by the surgical arm in this model). Two-way sensitivity analysis demonstrated that endoscopic resection would be the most cost-effective strategy if the cure rate from endoscopic surgery was greater than 90% and the complication rate was less than 1%. Monte Carlo simulation was performed for endoscopic surgery versus microscopic surgery at both time horizons. This analysis produced an incremental cost-effectiveness ratio of $80,235 per quality-adjusted life years at 5 years and $40,737 per quality-adjusted life years at 10 years, implying that with increasing time intervals, endoscopic transsphenoidal surgery is the more cost-effective treatment strategy. CONCLUSIONS: On the basis of the results of our model, transsphenoidal surgical resection of microprolactinomas, either microsurgical or endoscopic, appears to be more cost-effective than life-long medical therapy in young patients with life expectancy greater than 10 years. We caution that surgical resection for microprolactinomas be performed only in select cases by experienced pituitary surgeons at high-volume centers with high biochemical cure rates and low complication rates.

Transsphenoidal surgery for malignant pituitary lesions: an analysis of inpatient complications.

BACKGROUND: Fewer than 4% of pituitary tumors are malignant lesions. These tumors predominantly represent metastatic disease from elsewhere. This study evaluates inpatient complications, demographics, and hospitalization characteristics of patients who underwent transsphenoidal surgery (TSS) for malignant pituitary lesions. METHODS: The Nationwide Inpatient Sample was evaluated for TSS patients from 1998 to 2010. Demographics, hospitalization characteristics, and complications were evaluated among patients with malignant lesions and compared to those with benign tumors. RESULTS: There were 17,425 inpatient records, 1.0% of which involved malignant pituitary tumors. There was no difference in age between these cohorts (p = 0.378). Patients with malignant tumors had greater length of stay (6.7 days vs 4.5 days, p = 0.003) and higher trending charges ($55,371 vs $40,550 p = 0.091). The most common postoperative complications among patients with malignant lesions included diabetes insipidus (DI) (17.9%), fluid/electrolyte abnormalities (14.0%), neurological complications (5.6%), cerebrospinal fluid (CSF) rhinorrhea (2.2%), and iatrogenic pituitary disorders (2.2%). Patients with malignant lesions had a significantly greater rates of postoperative DI and fluid/electrolyte abnormalities (odds ratio = 2.0 and 1.7, respectively), whereas no statistical difference was noted in the rates of CSF rhinorrhea (p = 0.372). CONCLUSION: In this analysis of inpatient hospitalizations for TSS patients, malignant pituitary disease was associated with a greater rate of postoperative DI and fluid/electrolyte abnormalities, but no differences in the rates of postoperative CSF rhinorrhea and other complications were found. Patients with malignant pituitary lesions undergoing TSS had significantly longer hospitalizations and higher trending charges than those with benign lesions. This analysis is, however, subject to the limitations of the database.

Impact and cost of care of venous thromboembolism following pituitary surgery.

OBJECTIVES/HYPOTHESIS: In 2008, the Centers for Medicare and Medicaid Services discontinued reimbursement for postoperative venous thromboembolism (VTE) events such as deep venous thrombosis and pulmonary embolism, citing them as preventable postoperative complications. We examined the impact of postoperative VTE on patients undergoing pituitary surgery. METHODS: The Nationwide Inpatient Sample (NIS) was evaluated for patients undergoing pituitary resection from 2002 to 2010. Patient demographics, comorbidities, length of stay, hospital charges, and postoperative complications were analyzed. RESULTS: Eighty-seven patients who underwent pituitary surgery developed a VTE. Patients who underwent pituitary surgery that developed VTE were older (55.9 ± 15.2 years) than those who did not develop VTE (50.1 ± 17.2 years) (P = 0.002). VTE occurred at a significantly higher rate in patients with coagulopathy, peripheral vascular disorder, and weight loss (P < 0.05). VTE was associated with increased rates of postoperative neurological, pulmonary, cardiac, urinary, renal, hemorrhage, fluid and electrolytes, diabetes insipidus, and cerebrospinal fluid rhinorrhea complications (P < 0.01)-as well as increased mortality rate (P < 0.001), length of stay (P < 0.001), and cost of care (P < 0.001). CONCLUSIONS: Analysis of the data from the NIS database showed that risk factors for the development of VTE following pituitary surgery include older age, preexisting coagulopathy, peripheral vascular disorder, and weight loss. Patients who developed postoperative VTE had a longer length of hospital stay, higher hospital charges, and increased morbidity and mortality.

Reconstruction after retrosigmoid approaches using autologous fat graft-assisted Medpor Titan cranioplasty: assessment of postoperative cerebrospinal fluid leaks and headaches in 60 cases.

BACKGROUND: Postoperative cerebrospinal fluid (CSF) leaks and headaches remain potential complications after retrosigmoid approaches for lesions in the posterior fossa and cerebellopontine angle. The authors describe a simple repair technique with an autologous fat graft-assisted Medpor Titan cranioplasty and investigate the incidence of postoperative CSF leaks and headaches using this technique. METHODS: A retrospective chart review was conducted on all cases (n = 60) of retrosigmoid craniectomy from September 2009 to May 2014 in patients who underwent fat graft-assisted cranioplasty. After obtaining a watertight dural closure and sealing off any visible mastoid air cells with bone wax, an autologous fat graft was placed over the dural suture line and up against the waxed-off air cells. The fat graft filled the retrosigmoid cranial defect and was then bolstered with a Medpor Titan (titanium mesh embedded in porous polyethylene) cranioplasty. A postoperative mastoid pressure dressing was applied for 48 h, and prophylactic lumbar drainage was not used. Factors examined in this study included postoperative CSF leak (incisional, rhinorrhea, otorrhea), pseudomeningocele formation, incidence and severity of postoperative headache, length of hospital stay, and length of follow-up. RESULTS: No patients developed postoperative CSF leaks (0 %), pseudomeningoceles (0 %), or new-onset postoperative headaches (0 %) with the described repair technique. There were no cases of graft site morbidity such as hematoma or wound infection. Mean duration of postoperative hospital stay was 3.8 days (range 2-10 days). Mean postoperative follow-up was 12.4 months (range 2.0-41.1 months). CONCLUSIONS: Our multilayer repair technique with a fat graft-assisted Medpor Titan cranioplasty appears effective in preventing postoperative CSF leaks and new-onset postoperative headaches after retrosigmoid approaches. Postoperative lumbar drainage may not be necessary.

Assessing National Institutes of Health funding and scholarly impact in neurological surgery.

OBJECT: Research productivity is increasingly important in academic neurological surgery and can be measured through a variety of methods, such as publications, objective bibliometrics, and securing external grant support. The authors' objectives were to determine whether there is an association between scholarly impact, as measured by the h index, and successful National Institutes of Health (NIH) grant funding awarded to faculty in neurological surgery departments. METHODS: Primary investigators receiving National Institutes of Health (NIH) awards from Fiscal Years 2011-2013 were organized by academic rank, terminal degree, and their h index, as calculated from the Scopus database. These data were also obtained for nonfunded faculty from 15 randomly selected departments for comparison, and the average h index for each group was calculated. RESULTS: National Institutes of Health-funded faculty had higher average h indices than their nonfunded colleagues (23.6 vs 10.8, p < 0.0001), a finding that persisted upon controlling for academic rank. The mean h index increased with successive academic rank in both cohorts; greater funding totals were seen with successive academic position (Kruskal-Wallis, p < 0.05). National Institutes of Health-funded MDs had higher h indices than their PhD colleagues (p = 0.04), although funding levels did not differ significantly. There was a trend of increasing h index with higher NIH-funding ranges (p < 0.05). CONCLUSIONS: The authors' findings demonstrate a strong relationship between scholarly impact and securing NIH funding among faculty in academic neurosurgical departments. Faculty receiving a greater amount of funding tended to have a higher h index. Mean scholarly impact, as measured by the h index, increased with successive academic rank among both NIH-funded and nonfunded faculty, suggesting that this bibliometric may have utility as an adjunct in the academic appointment and promotion process in academic neurological surgery.