Comparison of telemedicine with in-person care for follow-up after elective neurosurgery: results of a cost-effectiveness analysis of 1200 patients using patient-perceived utility scores.

OBJECTIVE The utility of telemedicine (TM) in neurosurgery is underexplored, with most of the studies relating to teletrauma or telestroke programs. In this study, the authors evaluate the cost-effectiveness of TM consultations for follow-up care of a large population of patients who underwent neurosurgical procedures. METHODS A decision-analytical model was used to assess the cost-effectiveness of TM for elective post-neurosurgical care patients from a predominantly nonurban cohort in West Bengal, India. The model compared TM care via a nodal center in West Bengal to routine, in-person, per-episode care at the provider site in Bangalore, India. Cost and effectiveness data relating to 1200 patients were collected for a 52-month period. The effectiveness of TM care was calculated using efficiency in terms of the percentage of successful TM consultations, as well as patient-perceived utility values for overall experience of the type of health care access that they received. Incremental cost-effectiveness ratio (ICER) analysis was done using the 4-quadrant charting of the cost-effectiveness plane. One-way sensitivity and tornado analyses were performed to identify thresholds where the care strategy would change. RESULTS The overall utility for the 3 TM scenarios was found to be higher (89%) than for the utility of routine care (80%). TM was found to be more cost-effective (Indian rupee [INR] 2630 per patient) compared to routine care (INR 6848 per patient). The TM strategy "dominates" that of routine care by being more effective and less expensive (ICER value of -39,400 INR/unit of effectiveness). Sensitivity analysis revealed that cost-effectiveness of TM was most sensitive to changes in the number of TM patients, utility and success rate of TM, and travel distance to the TM center. CONCLUSIONS TM care dominates the in-person care strategy by providing more effective and less expensive follow-up care for a remote post-neurosurgical care population in India. In the authors' setting, this benefit of TM is sustainable even if half the TM consultations turn out to be unsuccessful. The viability of TM as a cost-effective care protocol is attributed to a combination of factors, like an adequate patient volume utilizing TM, patient utility, success rate of TM, and the patient travel distance.

Analogous Three-Dimensional Constructive Interference in Steady State Sequences Enhance the Utility of Three-Dimensional Time of Flight Magnetic Resonance Angiography in Delineating Lenticulostriate Arteries in Insular Gliomas: Evidence from a Prospective Clinicoradiologic Analysis of 48 Patients.

BACKGROUND: Three-dimensional (3D) time of flight (TOF) imaging is the current gold standard for noninvasive, preoperative localization of lenticulostriate arteries (LSAs) in insular gliomas; however, the utility of this modality depends on tumor intensity. METHODS: Over a 3-year period, 48 consecutive patients with insular gliomas were prospectively evaluated. Location of LSAs and their relationship with the tumor were determined using a combination of contrast-enhanced coronal 3D TOF magnetic resonance angiography and coronal 3D constructive interference in steady state (CISS) sequences. These findings were analyzed with respect to extent of tumor resection and early postoperative motor outcome. RESULTS: Tumor was clearly visualized in 29 (60.4%) patients with T1-hypointense tumors using 3D TOF and in all patients using CISS sequences. Using combined 3D TOF and CISS, LSA-tumor interface was well seen in 47 patients, including all patients with T1-heterointense or T1-isointense tumors. Extent of resection was higher in the LSA-pushed group compared with the LSA-encased group. In the LSA-encased group, 6 (12.5%) patients developed postoperative hemiparesis; 2 (4.2%) cases were attributed to LSA injury. CONCLUSIONS: Contrast-enhanced 3D TOF can delineate LSAs in almost all insular gliomas but is limited in identifying the LSA-tumor interface. This limitation can be overcome by addition of analogous CISS sequences that delineate the LSA-tumor interface regardless of tumor intensity. Combined 3D TOF and 3D CISS is a useful tool for surgical planning and safer resections of insular tumors and may have added surgical relevance when included as an intraoperative adjunct.

Pneumosinus dilatans of the spheno-ethmoidal complex associated with hypovitaminosis D causing bilateral optic canal stenosis.

INTRODUCTION: Pneumosinus dilatans (PSD) is a rare disorder of undetermined etiology characterized by expansion of the paranasal sinuses without bony erosion. Of the few cases of PSD described in indexed pediatric literature, there has been no reported case of this disorder presenting with optic canal stenosis in the setting of a vitamin deficiency. CASE MATERIAL: A 12-year-old girl presented with a 3-month history of progressive, painless, and asymmetric visual deterioration in her eyes. MRI showed prominent perioptic CSF spaces bilaterally and mild atrophy of both the optic nerves. CT head showed hyperpneumatization of the sphenoethmoidal air cells and both anterior clinoid processes with the optic nerves contained within narrowed intact bony canals. Blood investigations showed reduced vitamin D levels, and a subsequent skeletal survey showed diffuse osteopenia. She underwent endoscopic sphenoidotomy and bilateral decompression of the optic nerves. Following surgery, she reported improvement of vision in her left eye. She was started on vitamin D supplements for the endocrine abnormality. At a follow-up visit 6 months later, her visual acuity in both her eyes had improved. CONCLUSION: Pneumosinus dilatans is an unusual cause of progressive optic nerve dysfunction in the pediatric population. In the absence of any associated intracranial pathologies, conditions like hypovitamosis D should be ruled out.

Giant multi-compartmental suprasellar Rathke's cleft cyst with restriction on diffusion weighted images.

Rathke's cleft cysts are congenital lesions seen in sellar-suprasellar regions. We report a case of giant Rathke cyst in a 43-year-old patient with multi-compartmental involvement who presented with seizures with almost normal visual acuity. We discuss radiological and pathological features of various differential diagnoses for the giant suprasellar Rathke's cyst.

Paraspinal muscle morphometry in cervical spondylotic myelopathy and its implications in clinicoradiological outcomes following central corpectomy: clinical article.

OBJECT: The objective of this study was to assess the cross-sectional areas (CSAs) of the superficial, deep flexor (DF), and deep extensor (DE) paraspinal muscles in patients with cervical spondylotic myelopathy (CSM), and to evaluate their correlations with functional status and sagittal spinal alignment changes following central corpectomy with fusion and plating. METHODS: In this retrospective study of 67 patients who underwent central corpectomy with fusion and plating for CSM, the CSAs of the paraspinal muscles were calculated on the preoperative T2-weighted axial MR images and computed as ratios with respect to the corresponding vertebral body areas (VBAs) and as flexor/extensor CSA ratios. These ratios were then compared with those in the normative population and analyzed with respect to various clinicoradiological factors, including pain status, Nurick grade, and segmental angle change at follow-up (SACF). RESULTS: The mean CSA values for all muscle groups and the DF/DE ratio were significantly lower in the study cohort compared with an age- and sex-matched normative study group (p < 0.001). Among various independent variables tested in a multivariate regression analysis, increasing age and female sex significantly predicted a lower total extensor CSA/VBA ratio (p < 0.001), while a longer duration of symptoms significantly predicted a greater total flexor/total extensor CSA ratio (p = 0.02). In patients undergoing single-level corpectomy, graft subsidence had a positive correlation with SACF in all patients (p < 0.05), irrespective of the preoperative segmental angle and curvature, while in patients undergoing 2-level corpectomy, graft subsidence demonstrated such a correlation only in the subgroup with lordotic curvatures (p = 0.02). Among the muscle area ratios, the DF/DE ratio demonstrated a negative correlation with SACF in the subgroup with preoperative straight or kyphotic segmental angles (p = 0.04 in the single corpectomy group, p = 0.01 in the 2-level corpectomy group). There was no correlation of any of the muscle ratios with change in Nurick grade. CONCLUSIONS: Patients with CSM demonstrate significant atrophy in all the flexor and extensor paraspinal muscles, and also suffer a reduction in the protective effect of a strong DF/DE CSA ratio. Worsening of this ratio significantly correlates with greater segmental kyphotic change in some patients. A physiological mechanism based on DF dysfunction is discussed to elucidate these findings that have implications in preventive physiotherapy and rehabilitation of patients with CSM. Considering that the influence of a muscle ratio was significant only in patients with hypolordosis, a subgroup that is known to have facetal ligament laxity, it may also be postulated that ligamentous support supersedes the influence of paraspinal muscles on postoperative sagittal alignment in CSM.

Solitary thoracic vertebral body cysticercosis presenting with progressive compressive myelopathy.

Common bony spinal pathologies that could present with progressive spasticity include vertebral body tumors or chronic infections of the spine. Cysticercosis of the spine commonly has an intramedullary occurrence. The authors discuss the presentation and management of a rare case of solitary vertebral cysticercosis that presented with lower-limb spasticity and sphincter involvement.

Elderly Indo-Caribbean Hindus and end-of-life care: a community-based exploratory study.

America's increasingly diverse older population needs clinicians to be familiar with ethnic and cultural issues pertaining to end-of-life care (EOLC). Although there has been some work addressing these issues among African-American, Hispanic-American, and some Asian-American populations, data on the Asian-Indian and Hindu populations remain sparse. This community-based exploratory study surveyed older Indo-Caribbean Hindu people (a subset of the Hindu population living in America) attending a senior center in Queens, New York. This study describes the demographic and health characteristics of this population and examines their attitudes, knowledge, and beliefs regarding some EOLC issues. Data on participants' demographic, medical, psychosocial, and cognitive status were obtained. Previously validated scales were used to collect data on subjects' acculturation, religiosity, and EOLC beliefs. Participants had a mean age+/-standard deviation of 71.1+/-5.1 years; 43% were married. Prevalent illnesses included diabetes mellitus (48%), hypertension (66%), and arthritis (57%). Subjects were socially connected, moderately acculturated, and religious. Scores on the Ethnicity and Attitudes Towards EOLC Survey indicated negative beliefs about life-sustaining or prolonging technology and positive attitudes about advance care directives (ACDs), truth-telling, and family involvement. The number of ACDs that had been completed and knowledge about ACDs was low. The Indo-Caribbean elder population in this study expressed attitudes and beliefs regarding EOLC similar to those of other ethnic elders. Many of these beliefs are in conflict with current EOLC practice patterns. This highlights the importance of being aware of differing attitudes to provide sensitive EOLC.

Attitudes of Asian-Indian Hindus toward end-of-life care.

The population of older adults in the United States is increasing in cultural diversity. Thus, an appreciation of cultural perspectives regarding end-of-life care may benefit practicing physicians. This article addresses end-of-life care issues from the perspective of Hinduism--a faith embraced by a growing demographic of the U.S. population-and also reviews basic Hindu philosophical concepts salient to caring for patients at the end of life.