Application of broken windows theory to identify flow disruptions in neurosurgery procedure.

Addressing flow disruptions (FDs) in neurosurgery requires a multifaceted approach. Strategies like improved communication protocols, minimizing interruptions, improving coordination among team, optimizing operating room layout, and promoting user-centered design can help mitigate the challenges and enhance the overall flow and safety of neurosurgical procedures. Thirty neurosurgery cases were observed at two tertiary care facilities. The data collected were from wheels into the operating room to wheels out from the operating room. Data points were categorized using a human factors taxonomy known as RIPCHORD-TWA (Realizing Improved Patient Care Through Human-Centered Operating Room Design for Threat Window Analysis). Of the 541 total disruptions observed, coordination issues were the most prevalent (26.25%), followed by layout issues (26.06%), issues related to interruption (22.55%), communication (22.37%), equipment issues (2.40%) and usability issues (0.37%) comprised the remainder of the observations. This translated into one disruption every 2.7 min. Instead of focusing exclusively on errors and adverse events, we propose conceptualizing the accumulation of disruptions as "threat windows" to analyze potential threats to the integrity of the care system. This perspective allows for the improved identification of system weaknesses or threats, affording us the ability to address these inefficiencies and intervene before errors and adverse events may occur.

Cervical Spine and Craniocervical Junction Reconstruction with a Vascularized Fibula Free Flap.

BACKGROUND: Long-term stabilization of the cervical spine after extensive multilevel tumor resection is difficult to achieve. The current standard approach of instrumentation combined with allograft or nonvascularized autograft is limited in settings of increased risk of nonunion or delayed union (i.e., prior radiation therapy or poorly vascularized wound beds). CASE DESCRIPTION: We report the first time to our knowledge that a vascularized fibular free flap has been used to reconstruct the cervical column across 5 vertebral levels, from the craniocervical junction to the lower cervical spine. We describe a transoral approach to the area and compare this method with other reconstructive options. CONCLUSIONS: Vascularized bone grafting is a viable alternative to achieve lasting stability because of hastened fusion time, limited reliance on osseous remodeling, and incorporation into the axial skeleton with strut strength.

Acute Postoperative Unilateral Frontalis Palsy With Spontaneous Resolution After Placement of Mayfield Skull Clamp.

Cranial holders are used routinely in cranial and spinal surgery with rare reported complications, but frontalis palsy has not been reported as a complication of a Mayfield pin placement. Injury to the temporal nerve, a branch of the facial nerve that supplies the frontalis muscle, is possible because of its subcutaneous nature. A 78-year-old man presented after a fracture dislocation at C7-T1 following a ground level fall. He had progressive axial neck pain and clinical signs of C8 radiculopathy. The patient underwent elective C5-T2 fusion with an open reduction and internal fixation with the use of Mayfield skull immobilization. Postoperatively, he had right unilateral frontalis palsy. The patient was followed clinically for over 12 months and was treated conservatively without surgical intervention or nerve testing. He had spontaneous resolution of palsy with full recovery 2 months postoperatively. Proper placement of the Mayfield skull clamp is key to preventing complications. Knowledge of the landmarks for the temporal nerve assists in safe pin placement to avoid procedural morbidity. Frontalis palsy, if occurs, can be monitored for spontaneous resolution in the postoperative period.

Retro-Odontoid Pseudotumor with Cervical Medullary Compression: A Case Report.

A retro odontoid pseudo tumor is a mass lesion lying posterior to the odontoid process along the dura. It is a disease process seen in inflammatory and non-inflammatory conditions causing chronic atlanto-axial instability. This type of mass has the potential to enlarge causing cervicomedullary compression and symptoms of myelopathy. In the past, authors have relied on a more invasive, direct approach to decompress the mass including an anterior trans oral odontoidectomy and a posterior trans-dural resection. The objective of this case report is to describe the use of an indirect approach, cervical fusion with decompressive laminectomy, to successfully treat a retro odontoid pseudo tumor in a geriatric patient. A male patient in his late 90's presented with inability to ambulate, global paresis, and long tract signs in the upper extremities. He was found to have a large odontoid mass with compression at the cranio-cervical junction. He underwent cervical fusion with instrumented fixation from C1-6 and decompressive laminectomy from C4-6. Over a follow-up period of two years, there was improvement in the patient's motor weakness and ambulation. Radiographic evaluation at the two-year mark showed marked reduction in pannus size. Indirect approaches to decompression in patients with retro odontoid pseudo tumor using techniques such as cervical fusion may be a safe for effective treatment in patients of advanced age, with multiple co-morbidities, and inability to tolerate lengthy surgical procedures.