Carotid endarterectomy­safe and effective in a neurosurgeon's hands: a 25-year single-surgeon experience.

OBJECTIVE: Carotid endarterectomy (CEA) is a procedure performed by both vascular surgeons and neurosurgeons in the UK. We present a single neurosurgeon's experience of 728 CEAs over 25 years, performed under both general and local anesthesia, and discuss the results in this context. Our objective was to report on the efficacy of CEA in the hands of a neurosurgeon. METHODS: Prospective outcome data were collected for all patients who underwent CEA performed by the senior author (A.D.M.) from 1987 to 2011. Data evaluated included patient age, sex, surgical indication, preoperative characteristics, diagnostic modalities used, shunt usage, operative time, any neurological deterioration during or after surgery, and early postoperative problems. Outcome measures used were 30-day death and 30-day disabling stroke. The results were tabulated and analyzed using JMP 8.0.2 (SAS Inc., Cary, NC). RESULTS: The 30-day death rate was 0.8% and the 30-day disabling stroke rate was 1.7% in our series. The mean operative time was 135 minutes (±38.1), and the mean clamp time was 28.4 minutes (±8.5). In the subset of patients who had the operation performed under local anesthesia (n = 616), the disabling stroke rate was 1.6% and the death rate was 0.6%. In the subset of asymptomatic patients (n = 194), the 30-day death and 30-day disabling stroke rates were each 1%. Postoperative complications were uncommon. CONCLUSIONS: According to our data, CEA under local anesthesia is safe procedure in the hands of a neurosurgeon and would be recommended according to the clinical presentation and local guidelines.

Survey of inspection and palpation rates among spine providers: evaluation of physician performance of the physical examination for patients with low back pain.

STUDY DESIGN: Survey from July 2011 to April 2012 of adult patients with primary complaint of low back pain (LBP). OBJECTIVE: To determine the frequency of physical examination being performed by various providers, as measured by frequency of inspection and palpation, of patients with LBP and to describe patient ratings of these examinations. SUMMARY OF BACKGROUND DATA: The physical examination is a cornerstone of any evaluation of patients with LBP. With increasing reliance on diagnostic imaging, there is concern that patients are not being examined comprehensively, but to our knowledge, no studies have ever investigated how often the physical examination is performed in patients with LBP. METHODS: Survey participants were asked to list the types of physicians that they had seen for LBP within the past 1 year and for each physician encounter to answer 2 "yes/no" questions: (1) whether they had removed their clothes or put on a gown or shorts during the examination (our proxy for inspection) and (2) whether the provider had placed his or her hands on the patient (our proxy for palpation). Subjects also provided quality ratings for each provider's physical examination. Main outcome measures included frequency of inspection and palpation and subjects' ratings of each physical examination. RESULTS: A total of 295 surveys were collected reflecting 696 prior physician encounters. Inspection was done in 57% of physician encounters. Across specialties, orthopedic surgeons had the highest reported rate of inspection at 72%. The worst was among chiropractors at 40%. Palpation occurred in 80% of physician encounters. Chiropractors had the highest rate of palpation at 94%. The lowest rate was among neurosurgeons at 58%. CONCLUSION: Our data suggest that approximately 43% of patient visits for LBP involved no inspection and nearly 20% without palpation. These numbers reflect a need for improvement among providers who treat patients with LBP. LEVEL OF EVIDENCE: N/A.

A survey of complementary and alternative medicine (CAM) awareness among neurosurgeons in Washington State.

OBJECTIVES: Use of complementary and alternative medicine (CAM) by the U.S. population increased significantly in the past 2 decades. To maximize a patient's recovery from a neurosurgical procedure, it is critical that neurosurgeons be aware of the benefits and potential adverse complications of CAM therapies. The survey's purpose was to assess the current patterns of CAM utilization by neurosurgery patients and neurosurgeon knowledge of CAM therapies among Washington State Association of Neurological Surgeons (WSANS) members. METHODS: Members of the WSANS were surveyed in 2005. The survey was sent via e-mail and the data were anonymously collected using an online survey tool, Catalyst WebQ. RESULTS: The majority of responses (79%) stated that their neurosurgery practice was > or =75% adults. Acupuncture, herbs, massage therapy, prayer, and yoga were the most common CAM treatments patients used or discussed with their neurosurgeon. Fifty percent (50%) of neurosurgeons discussed the use of acupuncture among their colleagues. Concerning prayer and spirituality, 38% of the surveyed neurosurgeons stated that > or =25% of their patients have disclosed that they pray for their health; 42% stated that spirituality and prayer may affect neurosurgery outcome; and 38% stated that they pray for their patients. Overall, 63% of surveyed neurosurgeons stated that CAM treatments have a role in neurosurgery. CONCLUSIONS: The use of CAM may influence neurosurgical care; and the role of spirituality and prayer should be further explored. Because CAM utilization is ubiquitous, open discussion and familiarity with CAM treatments are becoming increasingly important in the field of neurosurgery.

Access to spine care: a tale of two cities.

INTRODUCTION: As governments struggle with increasing demand for accountability within the Canadian Health Care System and set wait-time standards, it is important to objectify data to allow a true understanding of present limitations and to facilitate comparisons to other systems. The purpose of this study was to compare wait list times for a cohort of patients requiring spinal surgery in Calgary, Alberta to a similar cohort in Sydney, Australia. METHODS: From January 1 until June 30, 2006 all outpatients admitted for spinal surgery to the Foothills Hospital were identified by the surgeons' office. Two time periods were quantified from their charts: (1) time from referral to surgical consultation; and (2) time from surgical consultation to operative intervention. From July 1 until December 31,2006 patients were similarly identified through Neurosurgical offices at the Prince of Wales Public and Private Hospitals in Sydney, Australia. RESULTS: Four hundred ninety-one surgical patients were captured during the six month period in Calgary and 155 patients during the subsequent six months in Sydney. The majority of patients in Sydney were treated in the Private Health Care system. Public patients in Sydney have access to a surgical consultant twice as fast as public patients in Calgary while private patients have access ten times faster. Access to operating room time within the public system is a rate limiting step in both countries. However, Sydney private patients receive their surgery four times faster than Calgary patients. CONCLUSIONS: Compared to Calgary, access to specialized spine care in Sydney appears more efficient not only in the Private but also the Public Health Care System. Part of this efficiency may arise from offloading from the public into the private system. Solutions proposed to reduce wait list times should consider benefits of a Private Health Care System.

Inappropriate acute neurosurgical bed occupancy and short falls in rehabilitation: implications for the National Service Framework.

Patients undergoing neurosurgical intervention may require different types of organized rehabilitation. A prospective study was performed of the care needs of neurosurgical inpatients between the ages of 16 and 70 years who were in acute wards for more than 2 weeks. Only 58% of bed occupancy days were devoted to essential acute neurosurgical ward management. This figure was even lower for patients admitted with subarachnoid haemorrhage (36%) or traumatic brain injury (38%). Overall, 21% of bed days would have more appropriately spent in 'rapid access'/acute rehabilitation beds, 13% in 'active participation' rehabilitation beds and 5% in cognitive/behavioural rehabilitation units. Addressing this unmet need would increase the availability of acute neurosurgery beds, without needing to build and staff more neurosurgery wards.

Development of neurosurgery in Greece: past, present, and future.

In this study the authors examine the historical tradition as well as current features of neurosurgery in Greece and compare the available data with international standards. In particular, they describe the organizational structure of neurosurgery with reference to manpower, unit distribution, training, and qualification. They discuss problems such as overproduction of neurosurgeons and the poor control of training and qualification procedures in the neurosurgical profession. The findings are examined in a critical way and solutions are proposed that could improve the present situation.

Valor pronóstico de la Escala de Glasgow en pacientes neuroquirúrgicos / Prognostic value of the Glasgow coma scale on neurosurgical patients

Se analizó el valor pronóstico de la Escala de Glasgow (EG) en 62 pacientes sometidos a neurocirugía intracraneana, correlacionando la EG en distintos tiempos (prequirúrgico, postoperatorio inmediato, mediato y tardío) con la Escala de Glasgow Evolutiva (EGE), representando ésta el valor de la evolución final obtenida en el momento del alta. Existiría una correlación inversa significativa entre EG y EGE, resultando la EG de las primeras 72 hs. del postoperatorio y del postoperatorio mediato como los valores mejor correlacionados con el escor evolutivo al alta. La escor en las primeras 72 hs. podría ser un predictor confiable de la evolución neuroquirúrgica (AU)

Valor pronóstico de la Escala de Glasgow en pacientes neuroquirúrgicos / Prognostic value of the Glasgow coma scale on neurosurgical patients

Se analizó el valor pronóstico de la Escala de Glasgow (EG) en 62 pacientes sometidos a neurocirugía intracraneana, correlacionando la EG en distintos tiempos (prequirúrgico, postoperatorio inmediato, mediato y tardío) con la Escala de Glasgow Evolutiva (EGE), representando ésta el valor de la evolución final obtenida en el momento del alta. Existiría una correlación inversa significativa entre EG y EGE, resultando la EG de las primeras 72 hs. del postoperatorio y del postoperatorio mediato como los valores mejor correlacionados con el escor evolutivo al alta. La escor en las primeras 72 hs. podría ser un predictor confiable de la evolución neuroquirúrgica