Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Setting with an Enhanced Recovery After Surgery Protocol.

OBJECTIVE: Enhanced Recovery After Surgery (ERAS) is a multidisciplinary approach to surgical care that aims to improve outcomes and reduce costs. Its application to spine surgery has been increasing in recent years, with a notable focus on lumbar fusion. This study describes the development, implementation, and outcomes of the first ERAS pathway for ambulatory spine surgery and the largest ambulatory minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) series to date. METHODS: A comprehensive protocol for ambulatory lumbar fusion is described, including patient selection criteria, a multimodal analgesia regimen, and discharge assessment. Consecutive patients undergoing 1- or 2-level MIS TLIF using the described protocol at a single ambulatory surgery center (ASC) over a five-year period were queried. RESULTS: A total of 215 patients underwent ambulatory MIS TLIF over the study period. There were no intraoperative or immediate postoperative complications. All but one patient (99.5%) were discharged home from the ASC. Almost three-quarters (71.2%) were discharged on the day of surgery. Thirty- and 90-day readmission rates were 1.4% and 2.8%, respectively. Only one readmission (0.5%) was for intractable back pain. There were no reoperations or mortalities within 90 days of surgery. CONCLUSIONS: MIS TLIF can be performed safely in a freestanding ambulatory surgery center with minimal perioperative and short-term morbidity. The addition of comprehensive ERAS protocols to the ambulatory setting can promote the transition of fusion procedures to this lower cost environment in an effort to provide higher value care.

Endoscopic Third Ventriculostomy and Endoscopic Intracranial Cyst Fenestration in an Outpatient Ambulatory Surgery Center Yields Reduced Cost But Equal Efficacy and Safety Compared with Surgery in the Hospital.

BACKGROUND: A transition is underway in neurosurgery to perform relatively safe surgeries outpatient, often at ambulatory surgery centers (ASC). We sought to evaluate whether simple intracranial endoscopic procedures such as third ventriculostomy and cyst fenestration can be safely and effectively performed at an ASC, while comparing costs with the hospital. METHODS: A retrospective chart review was performed for patients who underwent elective intracranial neuroendoscopic (NE) intervention at either a quaternary hospital or an affiliated ASC between August 2014 and September 2017. Groups were compared on length of stay, perioperative and 30-day morbidity, as well as clinical outcome at last follow-up. The total cost for these procedures were compared in relative units between all ASC cases and a small subset of hospital cases. RESULTS: In total, 16 NE operations performed at the ASC (mean patient age 29.8 years) and 37 at the hospital (mean age 15.4 years) with average length of stay of 3.5 hours and 23.1 hours respectively (P < 0.05). There were no acute complications in either cohort or morbid events requiring hospitalization within 30 days. Surgical success was noted for 75% of the ASC patients and 73% of the hospital cohort. The mean cost of 5 randomly selected hospital operations with same-day discharge and 5 with overnight stay was 3.4 and 4.1 times that of the ASC cohort, respectively (P < 0.05). CONCLUSIONS: Elective endoscopic third ventriculostomy and other simple NE procedures can be safely and effectively performed at an ASC for appropriate patients with significantly reduced cost compared with the hospital.

Redefining Mild Traumatic Brain Injury (mTBI) delineates cost effective triage.

OBJECTIVES: Mild traumatic brain injury (mTBI) is defined as Glasgow Coma Score (GCS) of 14 or 15. Despite good outcomes, patients are commonly transferred to trauma centers for observation and/or neurosurgical consultation. The aim of this study is to assess the value of redefining mTBI with novel radiographic criteria to determine the appropriateness of interhospital transfer for neurosurgical evaluation. METHODS: A retrospective study of patients with blunt head injury with GCS 13-15 and CT head from Jan 2014-Dec 2016 was performed. A novel criteria of head CT findings was created at our institution to classify mTBI. Outcomes included neurosurgical intervention and transfer cost. RESULTS: A total of 2120 patients were identified with 1442 (68.0%) meeting CT criteria for mTBI and 678 (32.0%) classified high risk. Two (0.14%) patients with mTBI required neurosurgical intervention compared with 143 (21.28%) high risk TBI (p < 0.0001). Mean age (55.8 years), and anticoagulation (2.6% vs 2.8%) or antiplatelet use (2.1% vs 3.0%) was similar between groups (p > 0.05). Of patients with mTBI, 689 were transferred without receiving neurosurgical intervention. Given an average EMS transfer cost of $700 for ground and $5800 for air, we estimate an unnecessary transfer cost of $733,600. CONCLUSION: Defining mTBI with the described novel criteria clearly identifies patients who can be safely managed without transfer for neurosurgical consultation. These unnecessary transfers represent a substantial financial and resource burden to the trauma system and inconvenience to patients.

Hemorrhagic direct traumatic carotid-cavernous fistula during endoscopic transsphenoidal surgery: intraoperative management and endovascular treatment.

Carotid-cavernous fistula (CCF) is a rare complication after transsphenoidal surgery with only 10 cases published (Ahuja et al., 1992; Cinar et al., 2013; Cossu et al., 2020; Dolenc et al., 1999; Kalia et al., 2009; Karaman et al., 2009; Kocer et al., 2002; Koitschev et al., 2006; Pigott et al., 1989; Takahashi et al., 1969). Intraoperative findings vary from unrecognized events to life-threatening hemorrhages. We provide a description of the management of an acute CCF occurring during sphenoidotomy in a patient with pituitary apoplexy. Osteotomy performed in the rostrum resulted in a fracture, which extended toward the intracavernous carotid artery. Bleeding was managed with mechanical compression. Endovascular treatment allowed closure of the fistula through transarterial coiling and glue. Arterial patency was preserved and the patient had no new neurological deficit. Drilling should be considered over osteotomy for the anterior sphenoidotomy. The video can be found here: https://youtu.be/0Me23xIVeNI.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Surgical Resection for the Treatment of Patients With Vestibular Schwannomas.

QUESTION 1: What surgical approaches for vestibular schwannomas (VS) are best for complete resection and facial nerve (FN) preservation when serviceable hearing is present? RECOMMENDATION: There is insufficient evidence to support the superiority of either the middle fossa (MF) or the retrosigmoid (RS) approach for complete VS resection and FN preservation when serviceable hearing is present. QUESTION 2: Which surgical approach (RS or translabyrinthine [TL]) for VS is best for complete resection and FN preservation when serviceable hearing is not present? RECOMMENDATION: There is insufficient evidence to support the superiority of either the RS or the TL approach for complete VS resection and FN preservation when serviceable hearing is not present. QUESTION 3: Does VS size matter for facial and vestibulocochlear nerve preservation with surgical resection? RECOMMENDATION: Level 3: Patients with larger VS tumor size should be counseled about the greater than average risk of loss of serviceable hearing. QUESTION 4: Should small intracanalicular tumors (<1.5 cm) be surgically resected? RECOMMENDATION: There are insufficient data to support a firm recommendation that surgery be the primary treatment for this subclass of VSs. QUESTION 5: Is hearing preservation routinely possible with VS surgical resection when serviceable hearing is present? RECOMMENDATION: Level 3: Hearing preservation surgery via the MF or the RS approach may be attempted in patients with small tumor size (<1.5 cm) and good preoperative hearing. QUESTION 6: When should surgical resection be the initial treatment in patients with neurofibromatosis type 2 (NF2)? RECOMMENDATION: There is insufficient evidence that surgical resection should be the initial treatment in patients with NF2. QUESTION 7: Does a multidisciplinary team, consisting of neurosurgery and neurotology, provides the best outcomes of complete resection and facial/vestibulocochlear nerve preservation for patients undergoing resection of VSs? RECOMMENDATION: There is insufficient evidence to support stating that a multidisciplinary team, usually consisting of a neurosurgeon and a neurotologist, provides superior outcomes compared to either subspecialist working alone. QUESTION 8: Does a subtotal surgical resection of a VS followed by stereotactic radiosurgery (SRS) to the residual tumor provide comparable hearing and FN preservation to patients who undergo a complete surgical resection? RECOMMENDATION: There is insufficient evidence to support subtotal resection (STR) followed by SRS provides comparable hearing and FN preservation to patients who undergo a complete surgical resection. QUESTION 9: Does surgical resection of VS treat preoperative balance problems more effectively than SRS? RECOMMENDATION: There is insufficient evidence to support either surgical resection or SRS for treatment of preoperative balance problems. QUESTION 10: Does surgical resection of VS treat preoperative trigeminal neuralgia more effectively than SRS? RECOMMENDATION: Level 3: Surgical resection of VSs may be used to better relieve symptoms of trigeminal neuralgia than SRS. QUESTION 11: Is surgical resection of VSs more difficult (associated with higher facial neuropathies and STR rates) after initial treatment with SRS? RECOMMENDATION: Level 3: If microsurgical resection is necessary after SRS, it is recommended that patients be counseled that there is an increased likelihood of a STR and decreased FN function. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_8.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Radiosurgery and Radiation Therapy in the Management of Patients With Vestibular Schwannomas.

Question: What are the indications for stereotactic radiosurgery (SRS) treatment vs observation for patients with intracanalicular vestibular schwannomas without evidence of radiographic progression? Recommendation: Level 3: If tinnitus is not observed at presentation, it is recommended that intracanalicular vestibular schwannomas and small tumors (<2 cm) without tinnitus be observed as observation does not have a negative impact on tumor growth or hearing preservation compared to treatment. Question: Is there a difference in outcome based on radiosurgery equipment used: Gamma Knife (Elekta, Stockholm, Sweden) vs linear accelerator-based radiosurgery vs proton beam? Recommendation: There are no studies that compare 2 or all 3 modalities. Thus, recommendations on outcome based on modality cannot be made. Question: Is there a difference in outcome based on the dose delivered? Recommendation: Level 3: As there is no difference in radiographic control using different doses, it is recommended that for single fraction SRS doses, <13 Gy be used to facilitate hearing preservation and minimize new onset or worsening of preexisting cranial nerve deficits. Question: Is there a difference in outcome based on the number of fractions? Recommendation: As there is no difference in radiographic control and clinical outcome using single or multiple fractions, no recommendations can be given. Question: What is the best time sequence for follow-up images after SRS? Recommendation: Level 3: Follow-up imaging should be obtained at intervals after SRS based on clinical indications, a patient's personal circumstances, or institutional protocols. Long-term follow-up with serial magnetic resonance imagings to evaluate for recurrence is recommended. No recommendations can be given regarding the interval of these studies. Question: Is there a role for retreatment? Recommendation: Level 3: When there has been progression of tumor after SRS, SRS can be safely and effectively performed as a retreatment. Question: What is the risk of radiation-induced malignant transformation of vestibular schwannomas treated with SRS? Recommendation: Level 3: Patients should be informed that there is minimal risk of malignant transformation of vestibular schwannomas after SRS. Question: What are the indications for SRS in patients with neurofibromatosis type 2? Recommendation: Level 3: Radiosurgery is a treatment option for patients with neurofibromatosis type 2 whose vestibular schwannomas are enlarging and/or causing hearing loss. The full guideline can be found at: https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_7.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Imaging in the Diagnosis and Management of Patients With Vestibular Schwannomas.

QUESTION 1: What sequences should be obtained on magnetic resonance imaging (MRI) to evaluate vestibular schwannomas before and after surgery? TARGET POPULATION: Adults with vestibular schwannomas. RECOMMENDATIONS: Initial Preoperative Evaluation Level 3: Imaging used to detect vestibular schwannomas should use high-resolution T2-weighted and contrast-enhanced T1-weighted MRI. Level 3: Standard T1, T2, fluid attenuated inversion recovery, and diffusion weighted imaging MR sequences obtained in axial, coronal, and sagittal plane may be used for detection of vestibular schwannomas. Preoperative Surveillance Level 3: Preoperative surveillance for growth of a vestibular schwannoma should be followed with either contrast-enhanced 3-dimensional (3-D) T1 magnetization prepared rapid acquisition gradient echo (MPRAGE) or high-resolution T2 (including constructive interference in steady state [CISS] or fast imaging employing steady-state acquisition [FIESTA] sequences) MRI. Postoperative Evaluation Level 2: Postoperative evaluation should be performed with postcontrast 3-D T1 MPRAGE, with nodular enhancement considered suspicious for recurrence. QUESTION 2: Is there a role for advanced imaging for facial nerve detection preoperatively (eg, CISS/FIESTA or diffusion tensor imaging)? TARGET POPULATION: Adults with proven or suspected vestibular schwannomas by imaging. RECOMMENDATION: Level 3: T2-weighted MRI may be used to augment visualization of the facial nerve course as part of preoperative evaluation. QUESTION 3: What is the expected growth rate of vestibular schwannomas on MRI, and how often should they be imaged if a "watch and wait" philosophy is pursued? TARGET POPULATION: Adults with suspected vestibular schwannomas by imaging. RECOMMENDATION: Level 3: MRIs should be obtained annually for 5 yr, with interval lengthening thereafter with tumor stability. QUESTION 4: Do cystic vestibular schwannomas behave differently than their solid counterparts? TARGET POPULATION: Adults with vestibular schwannomas with cystic components. RECOMMENDATION: Level 3: Adults with cystic vestibular schwannomas should be counseled that their tumors may more often be associated with rapid growth, lower rates of complete resection, and facial nerve outcomes that may be inferior in the immediate postoperative period but similar to noncystic schwannomas over time. QUESTION 5: Should the extent of lateral internal auditory canal involvement be considered by treating physicians? TARGET POPULATION: Adult patients with vestibular schwannomas. RECOMMENDATION: Level 3: The degree of lateral internal auditory canal involvement by tumor adversely affects facial nerve and hearing outcomes and should be emphasized when interpreting imaging for preoperative planning. QUESTION 6: How should patients with neurofibromatosis type 2 (NF2) and vestibular schwannoma be imaged and over what follow-up period? TARGET POPULATION: Adult patients with NF2 and vestibular schwannomas. RECOMMENDATION: Level 3: In general, vestibular schwannomas associated with NF2 should be imaged (similar to sporadic schwannomas) with the following caveats: 1. More frequent imaging may be adopted in NF2 patients because of a more variable growth rate for vestibular schwannomas, and annual imaging may ensue once the growth rate is established. 2. In NF2 patients with bilateral vestibular schwannomas, growth rate of a vestibular schwannoma may increase after resection of the contralateral tumor, and therefore, more frequent imaging may be indicated, based on the nonoperated tumor's historical rate of growth. 3. Careful consideration should be given to whether contrast is necessary in follow-up studies or if high-resolution T2 (including CISS or FIESTA-type sequences) MRI may adequately characterize changes in lesion size instead. QUESTION 7: How long should vestibular schwannomas be imaged after surgery, including after gross-total, near-total, and subtotal resection? TARGET POPULATION: Adult patients with vestibular schwannomas followed after surgery. RECOMMENDATION: Level 3: For patients receiving gross total resection, a postoperative MRI may be considered to document the surgical impression and may occur as late as 1 yr after surgery. For patients not receiving gross total resection, more frequent surveillance scans are suggested; annual MRI scans may be reasonable for 5 yr. Imaging follow-up should be adjusted accordingly for continued surveillance if any change in nodular enhancement is demonstrated. The full guideline can be found at https://www.cns.org/guidelines/guidelines-management-patients-vestibular-schwannoma/chapter_5.

The present and future of quality measures and public reporting in neurosurgery.

Quality measurement and public reporting are intended to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. However, regulatory implementation has created a complex network of reporting requirements for physicians and medical practices. These include Medicare's Physician Quality Reporting System, Electronic Health Records Meaningful Use, and Value-Based Payment Modifier programs. The common denominator of all these initiatives is that to avoid penalties, physicians must meet "generic" quality standards that, in the case of neurosurgery and many other specialties, are not pertinent to everyday clinical practice and hold specialists accountable for care decisions outside of their direct control. The Centers for Medicare and Medicaid Services has recently authorized alternative quality reporting mechanisms for the Physician Quality Reporting System, which allow registries to become subspecialty-reporting mechanisms under the Qualified Clinical Data Registry (QCDR) program. These programs further give subspecialties latitude to develop measures of health care quality that are relevant to the care provided. As such, these programs amplify the power of clinical registries by allowing more accurate assessment of practice patterns, patient experiences, and overall health care value. Neurosurgery has been at the forefront of these developments, leveraging the experience of the National Neurosurgery Quality and Outcomes Database to create one of the first specialty-specific QCDRs. Recent legislative reform has continued to change this landscape and has fueled optimism that registries (including QCDRs) and other specialty-driven quality measures will be a prominent feature of federal and private sector quality improvement initiatives. These physician- and patient-driven methods will allow neurosurgery to underscore the value of interventions, contribute to the development of sustainable health care solutions, and actively participate in meaningful quality initiatives for the benefit of the patients served.

The National Neurosurgery Quality and Outcomes Database Qualified Clinical Data Registry: 2015 measure specifications and rationale.

Meaningful quality measurement and public reporting have the potential to facilitate targeted outcome improvement, practice-based learning, shared decision making, and effective resource utilization. Recent developments in national quality reporting programs, such as the Centers for Medicare & Medicaid Services Qualified Clinical Data Registry (QCDR) reporting option, have enhanced the ability of specialty groups to develop relevant quality measures of the care they deliver. QCDRs will complete the collection and submission of Physician Quality Reporting System (PQRS) quality measures data on behalf of individual eligible professionals. The National Neurosurgery Quality and Outcomes Database (N(2)QOD) offers 21 non-PQRS measures, initially focused on spine procedures, which are the first specialty-specific measures for neurosurgery. Securing QCDR status for N(2)QOD is a tremendously important accomplishment for our specialty. This program will ensure that data collected through our registries and used for PQRS is meaningful for neurosurgeons, related spine care practitioners, their patients, and other stakeholders. The 2015 N(2)QOD QCDR is further evidence of neurosurgery's commitment to substantively advancing the health care quality paradigm. The following manuscript outlines the measures now approved for use in the 2015 N(2)QOD QCDR. Measure specifications (measure type and descriptions, related measures, if any, as well as relevant National Quality Strategy domain[s]) along with rationale are provided for each measure.

Polymeric drug delivery for the treatment of glioblastoma.

Glioblastoma (GBM) remains an almost universally fatal diagnosis. The current therapeutic mainstay consists of maximal safe surgical resection followed by radiation therapy (RT) with concomitant temozolomide (TMZ), followed by monthly TMZ (the "Stupp regimen"). Several chemotherapeutic agents have been shown to have modest efficacy in the treatment of high-grade glioma (HGG), but blood-brain barrier impermeability remains a major delivery obstacle. Polymeric drug-delivery systems, developed to allow controlled local release of biologically active substances for a variety of conditions, can achieve high local concentrations of active agents while limiting systemic toxicities. Polymerically delivered carmustine (BCNU) wafers, placed on the surface of the tumor-resection cavity, can potentially provide immediate chemotherapy to residual tumor cells during the standard delay between surgery and chemoradiotherapy. BCNU wafer implantation as monochemotherapy (with RT) in newly diagnosed HGG has been investigated in 2 phase III studies that reported significant increases in median overall survival. A number of studies have investigated the tumoricidal synergies of combination chemotherapy with BCNU wafers in newly diagnosed or recurrent HGG, and a primary research focus has been the integration of BCNU wafers into multimodality therapy with the standard Stupp regimen. Overall, the results of these studies have been encouraging in terms of safety and efficacy. However, the data must be qualified by the nature of the studies conducted. Currently, there are no phase III studies of BCNU wafers with the standard Stupp regimen. We review the rationale, biochemistry, pharmacokinetics, and research history (including toxicity profile) of this modality.