Rapid, midline retroperitoneal exposure for four-level anterior lumbar interbody fusion-technical case atlas.

We describe a novel, rapid midline retroperitoneal operative technique in a patient, with multi-level degenerative scoliosis, who underwent an extensive L2-S1 anterior lumbar interbody fusion in addition to posterior instrumentation. Uniquely, our approach enables an essentially midline approach to the rectus muscle and uses the diminution of the transversalis fascia-to-peritoneum transition in the pelvis to provide expedited exposure-making it particularly helpful for ALIF exposure, retraction and intraoperative radiography. We minimize morbidity around the rectus sheath by dissecting only the medial rectus muscle and then gently, bluntly mobilizing the retroperitoneum from the deep pelvis cranially.

Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs.

BACKGROUND: Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions. OBJECTIVE: To determine the proportion of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs. METHODS: We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed. RESULTS: Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7 ± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2% vs 4.1%) or an acute/inpatient rehabilitation facility (22.7% vs 1.7%, P < .0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P = .048). CONCLUSION: The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.

Correlation between the Oswestry Disability Index and the 4-item short forms for physical function and pain interference from PROMIS.

OBJECTIVE: The Oswestry Disability Index (ODI) is one of the most commonly used patient-reported outcome instruments, but completion of this 10-question survey can be cumbersome. Tools from the Patient-Reported Outcomes Measurement Information System (PROMIS) are an alternative, and potentially more efficient, means of assessing physical, mental, and social outcomes in spine surgery. Authors of this retrospective study assessed whether scores on the 4-item surveys of function and pain from the PROMIS initiative correlate with those on the ODI in lumbar spine surgery. METHODS: Patients evaluated in the adult neurosurgery spine clinic at a single institution completed the ODI, PROMIS Short Form v2.0 Physical Function 4a (PROMIS PF), and PROMIS Short Form v1.0 Pain Interference 4a (PROMIS PI) at various time points in their care. Score data were retrospectively analyzed using linear regressions with calculation of the Pearson correlation coefficient. RESULTS: Three hundred forty-three sets of surveys (ODI, PROMIS PF, and PROMIS PI) were obtained from patients across initial visits (n = 147), 3-month follow-ups (n = 107), 12-month follow-ups (n = 52), and 24-month follow-ups (n = 37). ODI scores strongly correlated with PROMIS PF t-scores at baseline (r = -0.72, p < 0.0001), 3 months (r = -0.79, p < 0.0001), 12 months (r = -0.85, p < 0.0001), and 24 months (r = -0.89, p < 0.0001). ODI scores also correlated strongly with PROMIS PI t-scores at baseline (r = 0.71, p < 0.0001), at 3 months (r = 0.82, p < 0.0001), at 12 months (r = 0.86, p < 0.0001), and at 24 months (r = 0.88, p < 0.0001). Changes in ODI scores moderately correlated with changes in PROMIS PF t-scores (r = -0.68, p = 0.0003) and changes in PROMIS PI t-scores (r = 0.57, p = 0.0047) at 3 months postoperatively. CONCLUSIONS: A strong correlation was found between the ODI and the 4-item PROMIS PF/PI at isolated time points for patients undergoing lumbar spine surgery. Large cohort studies are needed to determine longitudinal accuracy and precision and to assess possible benefits of time savings and improved rates of survey completion.

Length of Stay Beyond Medical Readiness in Neurosurgical Patients: A Prospective Analysis.

BACKGROUND: In an era of growing healthcare costs, there is increased pressure on medical care providers to discharge patients once they are medically fit. However, it is not uncommon for patients to stay beyond medical readiness (BMR). OBJECTIVE: To analyze the frequency with which patients remain in the hospital BMR. METHODS: A prospective cohort analysis utilizing a database maintained between 2014 and 2015 included 718 adults admitted to the neurosurgical service. The attending for admitted patients was asked on a daily basis as to whether the patient was medically cleared for discharge. Standard statistical analyses were performed. RESULTS: Of the 718 patients, 105 (14.6%) remained in the hospital BMR. Of the patients who presented with a spinal pathology, 17.8% had a length of stay (LOS)-BMR compared to 13.9% who presented with cerebrovascular pathologies and 14.8% who presented with a brain tumor. The average LOS-BMR was 1.8 d. Only 7.7% of patients who were discharged home had an LOS-BMR compared to 30.7% of patients who were discharged to a skilled nursing facility or rehabilitation center (P < .001). In logistic regression, a physical therapy consultation and discharge to a specialized nursing facility were both associated with a longer LOS (average 2.4 d longer, P < .001, and 6.2 d longer, P = .028, respectively). However, neither was associated with an LOS-BMR. CONCLUSION: LOS-BMR is an important process engineering concept within neurosurgery that represents a potential area for improvement to maximize limited healthcare resources. A sizeable portion of neurosurgical patients remained in the hospital BMR.

Variation in payments for spine surgery episodes of care: implications for episode-based bundled payment.

OBJECTIVE Spine surgery is expensive and marked by high variation across regions and providers. Bundled payments have potential to reduce unwarranted spending associated with spine surgery. This study is a cross-sectional analysis of commercial and Medicare claims data from January 2012 through March 2015 in the state of Michigan. The objective was to quantify variation in payments for spine surgery in adult patients, document sources of variation, and determine influence of patient-level, surgeon-level, and hospital-level factors. METHODS Hierarchical regression models were used to analyze contributions of patient-level covariates and influence of individual surgeons and hospitals. The primary outcome was price-standardized 90-day episode payments. Intraclass correlation coefficients-measures of variability accounted for by each level of a hierarchical model-were used to quantify sources of spending variation. RESULTS The authors analyzed 17,436 spine surgery episodes performed by 195 surgeons at 50 hospitals. Mean price-standardized 90-day episode payments in the highest spending quintile exceeded mean payments for episodes in the lowest cost quintile by $42,953 (p < 0.001). Facility payments for index admission and post-discharge payments were the greatest contributors to overall variation: 39.4% and 32.5%, respectively. After accounting for patient-level covariates, the remaining hospital-level and surgeon-level effects accounted for 2.0% (95% CI 1.1%-3.8%) and 4.0% (95% CI 2.9%-5.6%) of total variation, respectively. CONCLUSIONS Significant variation exists in total episode payments for spine surgery, driven mostly by variation in post-discharge and facility payments. Hospital and surgeon effects account for relatively little of the observed variation.

Does clinical improvement of symptomatic degenerative lumbar disease impact obesity?

OBJECTIVE Obesity and low-back pain associated with degenerative spondylosis or spondylolisthesis are common comorbid conditions. Many patients report that the pain and disability associated with degenerative lumbar disease are key factors in their inability to lose weight. The aim of this retrospective study was to determine if there is an association between improved functional status and weight loss following a successful transforaminal lumbar interbody fusion (TLIF) procedure. METHODS A retrospective cohort study of patients who underwent single-level TLIF was performed. Inclusion criteria were preoperative body mass index (BMI) greater than 30 kg/m2, achievement of minimum clinically important difference in the Oswestry Disability Index (ODI, defined as improvement of 15 points), and minimum 1-year postoperative followup BMI. Preoperative and postoperative BMI, ODI, and visual analog scale (VAS) scores were compared. A subgroup analysis of patients who achieved substantial clinical benefit (SCB, defined as a net improvement of 18.8 points on the ODI) was also performed. RESULTS A total of 56 patients met the inclusion criteria. The mean age of the study population was 55.6 ± 13.7 years. The mean preoperative BMI was 34.8 ± 4.6 kg/m2, the mean preoperative ODI was 66.2 ± 10.1, and the mean preoperative VAS score was 7.1 ± 1.7. The mean change in ODI was -33.1 ± 13.5 (p < 0.01) and the mean change in the VAS score was -4.1 ± 2.1 (p < 0.01). The mean change in BMI was +0.15 ± 2.1 kg/m2 (range -4.2 to +6.5 kg/m2; p = 0.6). SCB was achieved in 46 patients on the ODI. The mean preoperative BMI for patients with SCB was 34.8 ± 4.8 kg/m2, and the mean postoperative BMI was 34.7 ± 5.0 kg/m2. The mean change in BMI was -0.03 ± 1.9 kg/m2 (p = 0.9). CONCLUSIONS Despite successful surgical intervention via TLIF with achievement of improved function and pain, obese patients did not have significant change in weight postoperatively.

Neurosurgery and Telemedicine in the United States: Assessment of the Risks and Opportunities.

BACKGROUND: Telemedicine has seen substantial growth in the past 20 years, related to technologic advancements and evolving reimbursement policies. The risks and opportunities of neurosurgical telemedicine are nuanced. METHODS: We reviewed general and peer-reviewed literature as it relates to telemedicine and neurosurgery, with particular attention to best practices, relevant state and federal policy conditions, economic evaluations, and prospective clinical studies. RESULTS: Despite technologic development, growing interest, and increasing reimbursement opportunities, telemedicine's utilization remains limited because of concerns regarding an apparent lack of need for telemedicine services, lack of widespread reimbursement, lack of interstate licensure reciprocity, lack of universal access to necessary technology, concerns about maintaining patient confidentiality, and concerns and limited precedent regarding liability issues. The Veterans Health Administration, a component of the U.S. Department of Veterans Affairs, represents a setting in which these concerns can be largely obviated and is a model for telemedicine best practices. Results from the VA demonstrate substantial cost savings and patient satisfaction with remote care for chronic neurologic conditions. Overall, the economic and clinical benefits of telemedicine will likely come from 1) diminished travel times and lost work time for patients; 2) remote consultation of subspecialty experts, such as neurosurgeons; and 3) remote consultation to assist with triage and care in time-sensitive scenarios, including acute stroke care and "teletrauma." CONCLUSIONS: Telemedicine is effective in many health care scenarios and will become more relevant to neurosurgical patient care. We favor proceeding with legislation to reduce barriers to telemedicine's growth.

Radiation dose reduction during neurointerventional procedures by modification of default settings on biplane angiography equipment.

BACKGROUND: Neurointerventional procedures represent a significant source of ionizing radiation. We sought to assess the effect during neurointerventional procedures of varying default rates of radiation dose in fluoroscopy (F) and image acquisition (IA) modes, and frame rates during cine acquisition (CINE) on total X-ray dose, acquisition exposures, fluoroscopy time, and complications. METHODS: We retrospectively reviewed procedures performed with two radiation dose and CINE settings: a factory setting dose cohort (30 patients, F 45 nGy/pulse, IA 3.6 µGy/pulse, factory CINE frame rate) and a reduced dose cohort (30 patients, F 32 nGy/pulse, IA 1.2 µGy/pulse, with a decreased CINE frame rate). Total radiation dose, dose area product, number of acquisition exposures, fluoroscopy time, and complications were compared between the groups. Means comparisons (t tests) were employed to evaluate differences in the outcome variables between the two groups. p Value <0.05 was considered significant. RESULTS: The reduced dose cohort had a significant reduction in mean radiation dose (factory, 3650 mGy; reduced, 1650 mGy; p=0.005) and dose area product (factory, 34 700 µGy×m(2); reduced, 15 000 µGy×m(2); p=0.02). There were no significant differences between cohorts in acquisition exposure (p=0.73), fluoroscopy time (p=0.45), or complications. CONCLUSIONS: Significant reductions in radiation dose delivered by neurointerventional procedures can be achieved through simple modifications of default radiation dose in F and IA and frame rate during CINE without an increase in procedural complexity (fluoroscopy time) or rate of complications.

Prevalence of Chiari I Malformation and Syringomyelia.

Chiari I malformation (CM) is a common neurosurgical diagnosis and spinal cord syrinx is frequently found in patients with CM. Asymptomatic CM is a common imaging finding. Symptomatic CM is less common. Variation in prevalence estimates may be attributed to differences in sensitivity of CM detection between studies as well as differences in the populations being analyzed. The prevalence of low tonsil position and CM on MRI is higher in children and young adults compared with older adults. Studies that include a large number of older adults find a lower prevalence compared with analyses of children.

Management of recurrent aneurysms following endovascular therapy.

The aim of the current study is to describe the complication rates and clinical outcomes in patients who either underwent repeat intervention or conservative management with radiographic surveillance when presenting with aneurysmal recurrence after endovascular treatment. Since publication of the international subarachnoid aneurysm trial (ISAT), an increasing number of patients are treated with endovascular therapy. However, recurrence after endovascular therapy continues to pose a challenge, and there is minimal evidence to guide its management. We performed a retrospective review of all patients who underwent endovascular treatment of an intracranial aneurysm from January 2005 to February 2013. The patients who had an aneurysmal recurrence following the initial endovascular treatment were identified and divided into two groups: those followed with conservative management (n=24), and those who underwent reintervention (n=65). The groups were compared for complications and clinical outcomes. When a reintervention was undertaken, microsurgical clip ligation was associated with a higher rate of occlusion than additional endovascular therapy (p<0.001). When comparing conservative treatment and reintervention, there was no statistically significant difference in complications or clinical outcomes. Reintervention was more common in patients who were younger, had presented with subarachnoid hemorrhage, or had a greater degree of recurrence. We conclude that clinical outcomes and repeat subarachnoid hemorrhage are similar in patients who underwent retreatment versus those who had conservative management for their recurrent cerebral aneurysms.