Impact of Medicaid insurance on outcomes following endoscopic transsphenoidal pituitary surgery.

OBJECTIVE: Despite the rise of studies in the neurosurgical literature suggesting that patients with Medicaid insurance have inferior outcomes, there remains a paucity of data on the impact of insurance on outcomes after endonasal endoscopic transsphenoidal surgery (EETS). Given the increasing importance of complications in quality-based healthcare metrics, the objective of this study was to assess whether Medicaid insurance type influences outcomes in EETS for pituitary adenoma. METHODS: The authors analyzed a prospectively acquired database of EETS for pituitary adenoma from 2005 to 2018 at NewYork-Presbyterian Hospital, Weill Cornell Medicine. All patients with Medicaid insurance were identified. As a control group, the clinical, socioeconomic, and radiographic data of all other patients in the series with non-Medicaid insurance were reviewed. Statistical significance was determined with an alpha < 0.05 using Pearson chi-square and Fisher's exact tests for categorical variables and the independent-samples t-test for continuous variables. RESULTS: Of 584 patients undergoing EETS for pituitary adenoma, 57 (10%) had Medicaid insurance. The maximum tumor diameter was significantly larger for Medicaid patients (26.1 ± 12 vs 23.1 ± 11 mm for controls, p < 0.05). Baseline comorbidities including diabetes mellitus, hypertension, smoking history, and BMI were not significantly different between Medicaid patients and controls. Patients with Medicaid insurance had a significantly higher rate of any complication (14% vs 7% for controls, p < 0.05) and long-term cranial neuropathy (5% vs 1% for controls, p < 0.05). There were no statistically significant differences in endocrine outcome or vision outcome. The mean postoperative length of stay was significantly longer for Medicaid patients compared to the controls (9.4 ± 31 vs 3.6 ± 3 days, p < 0.05). This difference remained significant even when accounting for outliers (5.6 ± 2.5 vs 3.0 ± 2.7 days for controls, p < 0.05). The most common causes of extended length of stay greater than 1 standard deviation for Medicaid patients were management of perioperative complications and disposition challenges. The rate of 30-day readmission was 7% for Medicaid patients and 4.4% for controls, which was not a statistically significant difference. CONCLUSIONS: The authors found that larger tumor diameter, longer postoperative length of stay, higher rate of complications, and long-term cranial neuropathy were significantly associated with Medicaid insurance. There were no statistically significant differences in baseline comorbidities, apoplexy, endocrine outcome, vision outcome, or 30-day readmission.

Radiofrequency Ablation of Facial Venolymphatic Malformations: Assessment of Efficacy and Safety and the Role of Injectable Electrodes.

PURPOSE: To evaluate the efficacy and safety of ultrasound (US)-guided radiofrequency (RF) ablation in the treatment of facial microcystic lymphatic malformations (mLMs) or mixed venolymphatic malformations (VLMs) and to introduce the "induced-paralysis" technique with the use of an injectable electrode to minimize neural complications. MATERIALS AND METHODS: Data from patients with symptomatic facial mLMs or mixed VLMs who underwent US-guided RF ablation in 2014-2017 were retrospectively reviewed. Computed tomography (CT) and/or magnetic resonance (MR) imaging was used to localize any functional structures close to the target lesion. Treatment outcome was assessed by 4-point cosmetic grading score (CGS). Treatment outcome was compared between patients with vs without a functional structure close to the lesion and those treated with a noninjectable vs an injectable electrode. Immediate and late complications were assessed during follow-up. RESULTS: Data from 15 patients were evaluated. Initial CGS and median volume were significantly decreased at the last follow-up in all patients (from 4 to 1 and from 7 mL to 0.7 mL, respectively; P < .05). Treatment outcome differed significantly between those with and without a functional structure on CT or MR imaging (P < .05) but showed no difference between noninjectable (n = 9) and injectable electrodes (n = 6). Two cases of transient cranial nerve palsy were seen in the noninjectable electrode group. CONCLUSIONS: US-guided RF ablation is effective in patients with facial mLMs or mixed VLMs. The induced-paralysis technique with an injectable electrode has the potential to ensure technical safety without compromising efficacy.

Sjogren's syndrome: Clinical aspects.

Sjogren's syndrome (SS) is the 2nd most common chronic autoimmune rheumatic disease and associated with a high burden of illness. Morbidity arises not only from untreated xerostomia and keratoconjunctivitis sicca but also from extra-glandular manifestations including the development of non-Hodgkin's B cell lymphomas. Proper diagnosis of SS requires objective evidence of dry eyes and/or objective evidence of dry mouth as well as proof of autoimmunity. The recent development of new international classification criteria and clinical practice guidelines for SS should not only enhance the existing standards of care but also facilitate further studies to improve future diagnosis and outcomes.

Dural carotid-cavernous fistulas: epidemiology, clinical presentation, and management.

Dural arteriovenous fistulas of the cavernous sinus are no longer difficult to diagnose or treat. Specific ocular manifestations allow these fistulas to be diagnosed clinically. Noninvasive imaging techniques can be used to confirm the diagnosis. The most common treatment is endovascular occlusion of the lesion via a transarterial or transvenous route. Manual compression of the ipsilateral internal carotid artery in the neck or radiation therapy is appropriate in selected cases. Regardless of the treatment used, the fistula can be closed completely in most cases, resulting in restoration of normal orbital and intracranial blood flow and resolution of visual deficits.

Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study.

OBJECTIVE: Most studies on outcomes of carotid endarterectomy (CEA) have focused on the major complications of death and stroke. Less is known about minor but more common surgical complications such as hematoma, cranial nerve palsy, and wound infection. This study used data from a large, population-based cohort study to describe the incidence of minor surgical complications after CEA and examine associations between minor and major complications. METHODS: The New York Carotid Artery Surgery (NYCAS) study examined all Medicare beneficiaries who underwent CEA from January 1998 to June 1999 in NY State. Detailed clinical information on preoperative characteristics and complications < or =30 days of surgery was abstracted from hospital charts. Associations between minor (cranial nerve palsies, hematoma, and wound infection) and major complications (death/stroke) were examined with chi(2) tests and multivariate logistic regression. RESULTS: The NYCAS study had data on 9308 CEAs performed by 482 surgeons in 167 hospitals. Overall, 10% of patients had a minor surgical complication (cranial nerve (CN) palsy, 5.5%; hematoma, 5.0%; and wound infection, 0.2%). Cardiac complications occurred in 3.9% (myocardial 1.1%, unstable angina 0.9%, pulmonary edema 2.1%, and ventricular tachycardia 0.8%). In both unadjusted and adjusted analyses, the occurrence of any minor surgical complication, CN palsy alone, or hematoma alone was associated with 3 to 4-fold greater odds of perioperative stroke or combined risk of death and nonfatal stroke (P < 0.0001). Patients with cardiac complications had 4 to 5-fold increased odds of stroke or combined risk of death and stroke. CONCLUSION: Minor surgical complications are common after CEA and are associated with much higher risk of death and stroke. Patient factors, process factors, and direct causality are involved in this relationship, but future work will be needed to better understand their relative contributions.

Neurosensory disturbances of the inferior alveolar nerve: a retrospective study of complaints in a 10-year period.

PURPOSE: The aim of this study was to evaluate the prevalence of neurosensory disturbances (NSDs) of the inferior alveolar nerve after dental procedures. MATERIALS AND METHODS: A retrospective study of patient complaints for transient and permanent NSDs was achieved by means of a 10-year follow-up of claims to a national practitioner insurance company. Claims for 3 different dental procedures were analyzed from 157,292 contracts of insurance recorded during this period. RESULTS: Three hundred eighty-two complaints of NSDs were recorded with 75 permanent injuries (19.6%). The incidence of endodontic treatment and surgical procedures in NSDs cases were 35.3% and 61.5%, respectively, and the prevalence of third molar removals in permanent loss of sensation was 46.6%. CONCLUSION: Impacted third molar removal appears to be the main etiology of permanent inferior alveolar nerve sensory deficiency, but endodontic treatments are often implicated and implant placement procedures can cause severe nerve injuries.

Surgical management of petroclival meningiomas: defining resection goals based on risk of neurological morbidity and tumor recurrence rates in 137 patients.

OBJECTIVE: Meningiomas arising from the petroclival region remain a challenging surgical problem. Because of the substantial risk of neurological morbidity, uniformly pursuing a gross total resection (GTR) to minimize tumor recurrence rates may not be justified. We sought to define optimal resection goals based on risk factors for postoperative neurological morbidity and tumor recurrence rates. METHODS: This series represents our experience with 137 meningiomas arising from the petroclival region resected between June 1993 and October 2002. There were 38 male and 99 female patients with a mean age of 53 years. RESULTS: GTR was achieved in 40% of patients, and near total resection (NTR) was achieved in 40% of patients. One operative death occurred. Twenty-six percent of patients experienced new postoperative cranial nerve deficits, paresis, or ataxia when assessed at a mean follow-up of 8.3 months. The risk of cranial nerve deficits increased with prior resection (P < 0.001), preoperative cranial nerve deficit (P = 0.005), tumor adherence to neurovascular structures (P = 0.046), and fibrous tumor consistency (P = 0.005). The risk of paresis or ataxia increased with prior resection (P = 0.001) and tumor adherence (P = 0.045). Selective NTR rather than GTR in patients with adherent or fibrous tumors significantly reduced the rate of neurological deficits. Radiographic recurrence or progression occurred in 17.6% of patients at a mean follow-up of 29.8 months. Tumor recurrence rates after GTR and NTR did not differ significantly (P = 0.111). CONCLUSION: Intraoperatively defined tumor characteristics played a critical role in identifying the subset of patients with an increased risk of postoperative deficits. By selectively pursuing an NTR rather than a GTR, neurological morbidity was reduced significantly without significantly increasing the rate of tumor recurrence.

Assessment of material- and technique-related complications following sagittal split osteotomies stabilized by biodegradable polylactide screws.

OBJECTIVE: The aim of this retrospective clinical study was to determine whether there are any material-related problems and increased occurrence of postoperative mandibular nerve and temporomandibular joint dysfunctions in connection with the use of biodegradable self-reinforced poly-L-lactide (SR-PLLA) screws for bone fixation after bilateral sagittal split osteotomies (BSSO). STUDY DESIGN: Forty consecutive patients who underwent BSSO and mandibular advancement that included fragment fixation using SR-PLLA screws were monitored for an average of 2.2 years postoperatively. RESULTS: The osteotomy sites healed uneventfully with no adverse reactions. The incidence of postoperative sensory disturbances of the inferior alveolar nerve was 27%. Symptoms of temporomandibular joint disorders (TMJD) observed preoperatively in 73% of patients were reduced to 48% after surgery. CONCLUSION: The occurrence of postoperative sensory disturbances and TMJD symptoms in this study did not deviate strikingly from that of other studies using conventional osteosynthesis. No specific complications related to the screw material were observed.

Management of the small acoustic neuroma: a decision analysis.

Imaging techniques such as magnetic resonance imaging (MRI) with gadolinium may detect small acoustic neuromas before significant symptoms have developed. In this situation, the patient and surgeon may question whether the tumor requires treatment, especially if the tumor was discovered incidentally. A computerized clinical decision analysis was undertaken to model the decision to observe such tumors or proceed to immediate surgery. The decision tree was constructed with flexibility to account for tumor size, hearing level, and other critical variables such as the individual's aversion to unilateral hearing loss and facial paralysis. Unless life expectancy is short, the analysis suggests that surgery at the time of diagnosis is appropriate, assuming that growth of the tumor is anticipated. Variations in surgical proficiency and patient risk aversion within expected ranges do not influence the decision to operate. The most critical variable appears to be the probability that the tumor will remain stable in size. This finding suggests that better data regarding the growth rate of small acoustic neuromas is needed.

Thermography for the clinical assessment of inferior alveolar nerve deficit: a pilot study.

Neurosensory deficit is a major complication encountered in maxillofacial surgery. This study assessed the ability of electronic thermography to identify inferior alveolar nerve deficits in a pilot clinical study. The study population comprised six patients with inferior alveolar nerve deficit and 12 normal subjects. Frontally projected facial thermograms were taken on 18 subjects and measured using an Agema 870 unit and thermal image computer. Mathematical analysis of thermal measurements included temperature and delta T calculations of the anatomic zone over the mental region of the face. Results included (1) high levels of thermal symmetry of the chin in normal subjects (delta T = 0.1 degree C, standard deviation = 0.1 degree C); (2) low levels of thermal symmetry in patients with inferior alveolar nerve deficits (delta T = +0.5 degree C, standard deviation = 0.2 degree C); (3) statistically significant differences in delta T values (t = 4.82, P > .001) in patients with inferior alveolar nerve deficit; and (4) absolute temperature variations of the mental region in both groups. This pilot study demonstrated thermal asymmetry in patients with inferior alveolar nerve deficit and suggests that electronic thermography has promise as a simple, objective, noninvasive method for evaluating nerve deficits. However, more extensive studies are needed before thermographic procedures are accepted clinically.

Thermographic assessment of reversible inferior alveolar nerve deficit.

The purpose of this study was to investigate thermography's potential as a diagnostic alternative for evaluating neurosensory deficits of the inferior alveolar nerve. Electronic thermography was used to evaluate the alterations in facial thermal patterns attendant to a conduction defect of the inferior alveolar nerve induced in 12 subjects using 2% lidocaine. The rates of onset and duration of sensory block, as visualized by thermography, were related to the results of conventional neurosensory testing. Comparison of the rate of response change within each measurement system revealed that changes in facial skin temperature manifest the induced deficit earlier than discriminative tests. Also, the prolonged elevation of thermal asymmetry suggested that electronic thermography has the ability to detect subtle changes in nerve function that are not discernible by physical neurosensory tests relying on patient response. Although cutaneous temperature increases were highest in the field of observation near the sensory distribution of the mental nerve, an inexplicable warming of the contralateral side of the face and neck was also observed. These attendant findings emphasize the need for further studies on the pathophysiologic mechanisms of facial thermal changes to better understand thermography's diagnostic accuracy and clinical utility for monitoring inferior alveolar nerve dysfunction.

The radiologic assessment of trigeminal neuropathy.

The clinical and radiologic records of 76 patients with trigeminal neuropathy and an abnormal imaging study (CT and/or MR) were analyzed retrospectively. The trigeminal nerve (cranial nerve V) was divided into proximal (brainstem, preganglionic, gasserian ganglion, and cavernous sinus) and distal (extracranial V1, V2, and V3) segments. Lesions were organized according to segments and correlated with the type and distribution of clinical symptoms or signs. The purpose of the study was to (1) determine the efficacy of clinical localization of cranial nerve V lesions, (2) compare CT and MR for cranial nerve V imaging, (3) develop an MR protocol for effective cranial nerve V imaging, and (4) construct a differential diagnosis by anatomic segment for lesions of cranial nerve V. Clinical localization was found to be extremely inaccurate. CT was not as sensitive as MR for lesions involving the basal cisterns and skull base and will not detect the most common brainstem lesions (small infarcts and multiple sclerosis plaques). The MR protocol developed does not rely heavily on clinical localization. On the basis of lesions found in this series, a differential diagnosis by segment was developed. Patients with cranial nerve V symptoms should undergo MR imaging according to the protocol provided in this article. CT is not as effective as MR in imaging some cranial nerve V segments. Clinical localization is inaccurate.

The radiologic assessment of trigeminal neuropathy.

The clinical and radiologic records of 76 patients with trigeminal neuropathy and an abnormal imaging study (CT and/or MR) were analyzed retrospectively. The trigeminal nerve (cranial nerve V) was divided into proximal (brainstem, preganglionic, gasserian ganglion, and cavernous sinus) and distal (extracranial V1, V2, and V3) segments. Lesions were organized according to segments and correlated with the type and distribution of clinical symptoms or signs. The purpose of the study was to (1) determine the efficacy of clinical localization of cranial nerve V lesions, (2) compare CT and MR for cranial nerve V imaging, (3) develop an MR protocol for effective cranial nerve V imaging, and (4) construct a differential diagnosis by anatomic segment for lesions of cranial nerve V. Clinical localization was found to be extremely inaccurate. CT was not as sensitive as MR for lesions involving the basal cisterns and skull base and will not detect the most common brainstem lesions (small infarcts and multiple sclerosis plaques). The MR protocol developed does not rely heavily on clinical localization. On the basis of lesions found in this series, a differential diagnosis by segment was developed. Patients with cranial nerve V symptoms should undergo MR imaging according to the protocol provided in this article. CT is not as effective as MR in imaging some cranial nerve V segments. Clinical localization is inaccurate.