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A mentorship model for neurosurgical training: the Mayo Clinic experience

Rohin Singh, Nicole M. De La Peña, Paola Suarez-Meade, Panagiotis Kerezoudis, Oluwaseun O. Akinduro, Kaisorn L. Chaichana, Alfredo Quiñones-Hinojosa, Bernard R. Bendok, Mohamad Bydon, Fredric B. Meyer, Robert J. Spinner, and David J. Daniels

Neurosurgical education is a continually developing field with an aim of training competent and compassionate surgeons who can care for the needs of their patients. The Mayo Clinic utilizes a unique mentorship model for neurosurgical training. In this paper, the authors detail the historical roots as well as the logistical and experiential characteristics of this teaching model.

This model was first established in the late 1890s by the Mayo brothers and then adopted by the Mayo Clinic Department of Neurological Surgery at its inception in 1919. It has since been implemented enterprise-wide at the Minnesota, Florida, and Arizona residency programs. The mentorship model is focused on honing resident skills through individualized attention and guidance from an attending physician. Each resident is closely mentored by a consultant during a 2- or 3-month rotation, which allows for exposure to more complex cases early in their training.

In this model, residents take ownership of their patients’ care, following them longitudinally during their hospital course with guided oversight from their mentors. During the chief year, residents have their own clinic, operating room (OR) schedule, and OR team and service nurse. In this model, chief residents conduct themselves more in the manner of an attending physician than a trainee but continue to have oversight from staff to provide a “safety net.” The longitudinal care of patients provided by the residents under the mentorship model is not only beneficial for the trainee and the hospital, but also has a positive impact on patient satisfaction and safety. The Mayo Clinic Mentorship Model is one of many educational models that has demonstrated itself to be an excellent approach for resident education.

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Positive impact of the pandemic: the effect of post–COVID-19 virtual visit implementation on departmental efficiency and patient satisfaction in a quaternary care center

Zach Pennington, Giorgos D. Michalopoulos, Aaron J. Biedermann, Jeffrey R. Ziegler, Sherri L. Durst, Robert J. Spinner, Fredric B. Meyer, David J. Daniels, and Mohamad Bydon

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has significantly changed clinical practice across US healthcare. Increased adoption of telemedicine has emerged as an alternative to in-person contact for patient-physician interactions. The aim of this study was to analyze the impact of telemedicine on workflow and care delivery from January 2019 to December 2021 in a neurosurgical department at a quaternary care center.

METHODS

Prospectively captured data on clinic appointment utilization, duration, and outcomes were queried. Visits were divided into in-person visits and telemedicine appointments, categorized as follow-up visits of previously surgically treated patients, internal consultations, new patient visits, and early postoperative returns after surgery. Appointment volume was compared pre- and postpandemic using March 2020 as the pandemic onset. Clinical efficiency was measured by time to appointment, rate of on-time appointments, proportion of appointments resulting in surgical intervention (surgical yield), and patient-reported satisfaction, the latter measured as the proportion of patients indicating “high likelihood to recommend practice.”

RESULTS

A total of 54,562 visits occurred, most commonly for follow-up for previously operated patients (51.8%), internal new patient referrals (24.5%), and external new patient referrals (19.8%). Total visit volume was stable pre- to postpandemic (1521.3 vs 1512, p = 0.917). However, in-person visits significantly decreased (1517/month vs 1220/month, p < 0.001), with a nadir in April 2020, while telemedicine appointment utilization increased significantly (0.3% vs 19.1% of all visits). Telemedicine utilization remained stable throughout the 1st calendar year following the pandemic. Telemedicine appointments were associated with shorter time to appointment than in-person visits both before and after the pandemic onset (0–5 days from appointment request: 60% vs 33% vs 29.8%, p < 0.001). Patients had on-time appointments in 87% of telemedicine encounters. Notably, telemedicine appointments resulted in surgery in 31.8% of internal consultations or new patient visits, a significantly lower rate than that for in-person visits (51.8%). After the widespread integration of telemedicine, patient satisfaction for all visits was higher than before the pandemic onset (85.9% vs 88.5%, p = 0.027).

CONCLUSIONS

Telemedicine use significantly increased following the pandemic onset, compensating for observed decreases in face-to-face visits. Utilization rates have remained stable, suggesting effective integration, and delays between referrals and appointments were lower than for in-person visits. Importantly, telemedicine integration was not associated with a decrease in overall patient satisfaction, although telemedicine appointments had a lower surgical yield. These data suggest that telemedicine smoothened the impact of the pandemic on clinical workflow and helped to maintain continuity and quality of outpatient care.

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Building and implementing an institutional registry for a data-driven national neurosurgical practice: experience from a multisite medical center

Mohamad Bydon, Anshit Goyal, Aaron Biedermann, Allie J. Canoy Illies, Travis Paul, Abdul Karim Ghaith, Bernard Bendok, Alfredo Quiñones-Hinojosa, Robert J. Spinner, and Fredric B. Meyer

In an era when healthcare “value” remains a much-emphasized concept, measuring and reporting the quality of neurosurgical care and costs remains a challenge for large multisite health systems. Ensuring cohesion in outcomes across multiple sites is important to the development of a holistic competitive marketing strategy that seeks to promote “brand” performance characterized by a superior quality of patient care. This requires mechanisms for data collection and development of a single uniform outcomes measurement system site wide. Operationalizing a true multidisciplinary effort in this space requires intersection of a vast array of information technology and administrative resources along with the neurosurgeons who provide subject-matter expertise relevant to patient care. To measure neurosurgical quality and safety as well as improve payor contract negotiations, a practice analytics dashboard was created to allow summary visualization of operational indicators such as case volumes, quality outcomes, and relative value units and financial indicators such as total hospital costs and charges in order to provide a comprehensive overview of the “value” of surgical care. The current version of the dashboard summarizes these metrics by site, surgeon, and procedure for nearly 30,000 neurosurgical procedures that have been logged into the Mayo Clinic Enterprise Neurosurgery Registry since transition to the Epic electronic health record (EHR) system. In this article, the authors sought to review their experience in launching this EHR-linked data-driven neurosurgical practice initiative across a large, national multisite academic medical center.

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Introduction: the value of peripheral nerve surgery

Robert J. Spinner, Holly S. Gilmer, and Gregory R. Trost

If a single picture is worth a thousand words, then a video, by logical extension, would be priceless. This edition showcases peripheral nerve surgery in all its grandeur and preserves it for posterity. Classic and novel surgical techniques are shown related to tumor biopsy or resection; nerve decompression for entrapment; and nerve reconstruction with direct repair or nerve transfer. Akin to a nautical chart filled with detailed maps for sailors, this Neurosurgical Focus Video Atlas provides navigational tools for neurosurgeons. The shared underlying message is that a sound knowledge of anatomy can lead to innovation (i.e., creative approaches or solutions) and excellence (i.e., improved patient outcomes).

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Targeted fascicular biopsy in a patient with prostate cancer

Jonathan J. Stone, Megan C. Kaszuba, and Robert J. Spinner

Patients who present with a history of cancer and the new onset of lumbosacral or peripheral neuropathy should be evaluated for the potential of metastasis. Targeted fascicular biopsy can be useful to diagnose atypical lesions within peripheral nerves in patients with major or progressive neurological deficits. In this video, the authors demonstrate the technique of targeted fascicular biopsy of the sciatic nerve in a 63-year-old man with a history of prostate cancer.

The video can be found here: https://youtu.be/PTOX9XxNBDU.

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Abstracts of the 2017 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves Las Vegas, Nevada • March 8–11, 2017

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Introduction: Peripheral nerve surgery

Mark A. Mahan, Wilson Z. Ray, Lynda J. S. Yang, and Robert J. Spinner

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The nearly invisible intraneural cyst: a new and emerging part of the spectrum

Thomas J. Wilson, Marie-Noëlle Hébert-Blouin, Naveen S. Murthy, Joaquín J. García, Kimberly K. Amrami, and Robert J. Spinner

OBJECTIVE

The authors have observed that a subset of patients referred for evaluation of peroneal neuropathy with “negative” findings on MRI of the knee have subtle evidence of a peroneal intraneural ganglion cyst on subsequent closer inspection. The objective of this study was to introduce the nearly invisible peroneal intraneural ganglion cyst and provide illustrative cases. The authors further wanted to identify clues to the presence of a nearly invisible cyst.

METHODS

Illustrative cases demonstrating nearly invisible peroneal intraneural ganglion cysts were retrospectively reviewed and are presented. Case history and physical examination, imaging, and intraoperative findings were reviewed for each case. The outcomes of interest were the size and configuration of peroneal intraneural ganglion cysts over time, relative to various interventions that were performed, and in relation to physical examination and electrodiagnostic findings.

RESULTS

The authors present a series of cases that highlight the dynamic nature of peroneal intraneural ganglion cysts and introduce the nearly invisible cyst as a new and emerging part of the spectrum. The cases demonstrate changes in size and morphology over time of both the intraneural and extraneural compartments of these cysts. Despite “negative” MR imaging findings, nearly invisible cysts can be identified in a subset of patients.

CONCLUSIONS

The authors demonstrate here that peroneal intraneural ganglion cysts ride a roller coaster of change in both size and morphology over time, and they describe the nearly invisible cyst as one end of the spectrum. They identified clues to the presence of a nearly invisible cyst, including deep peroneal predominant symptoms, fluctuating symptoms, denervation changes in the tibialis anterior muscle, and abnormalities of the superior tibiofibular joint, and they correlate the subtle imaging findings to the internal fascicular topography of the common peroneal nerve. The description of the nearly invisible cyst may allow for increased recognition of this pathological entity that occurs with a spectrum of findings.

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Targeted fascicular biopsy of the brachial plexus: rationale and operative technique

Pierre Laumonerie, Stepan Capek, Kimberly K. Amrami, P. James B. Dyck, and Robert J. Spinner

OBJECTIVE

Nerve biopsy is useful in the management of neuromuscular disorders and is commonly performed in distal, noncritical cutaneous nerves. In general, these procedures are diagnostic in only 20%–50%. In selected cases in which preoperative evaluation points toward a more localized process, targeted biopsy would likely improve diagnostic yield. The authors report their experience with targeted fascicular biopsy of the brachial plexus and provide a description of the operative technique.

METHODS

All cases of targeted biopsy of the brachial plexus biopsy performed between 2003 and 2015 were reviewed. Targeted nerve biopsy was performed using a supraclavicular, infraclavicular, or proximal medial arm approach. Demographic data and clinical presentation as well as the details of the procedure, adverse events (temporary or permanent), and final pathological findings were recorded.

RESULTS

Brachial plexus biopsy was performed in 74 patients (47 women and 27 men). The patients' mean age was 57.7 years. All patients had abnormal findings on physical examination, electrodiagnostic studies, and MRI. The overall diagnostic yield of biopsy was 74.3% (n = 55). The most common diagnoses included inflammatory demyelination (19), breast carcinoma (17), neurolymphomatosis (8), and perineurioma (7). There was a 19% complication rate; most of the complications were minor or transient, but 4 patients (5.4%) had increased numbness and 3 (4.0%) had additional weakness following biopsy.

CONCLUSIONS

Targeted fascicular biopsy of the brachial plexus is an effective diagnostic procedure, and in highly selected cases should be considered as the initial procedure over nontargeted, distal cutaneous nerve biopsy. Using MRI to guide the location of a fascicular biopsy, the authors found this technique to produce a higher diagnostic yield than historical norms as well as providing justification for definitive treatment.

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The almost-invisible perineurioma

Carlos E. Restrepo, Kimberly K. Amrami, Benjamin M. Howe, P. James B. Dyck, Michelle L. Mauermann, and Robert J. Spinner

Intraneural perineurioma is a rare, benign slow-growing lesion arising from the perineurial cells that surrounds the peripheral nerve fibers. Typically it presents during childhood and young adulthood as a motor mononeuropathy. MRI plays an essential role in the diagnosis and localization of the lesion, which appears as a fusiform enlargement of the nerve fascicles that enhances intensely with gadolinium. Despite the typical clinical and radiological features, intraneural perineurioma remains largely underdiagnosed because of the lack of familiarity with this entity, but also as a result of technical limitations with conventional MRI that is typically performed as a screening test over a large field of view and without contrast sequences. The purpose of this article is to present the pitfalls and pearls learned from years of experience in the diagnosis and management of this relatively rare condition.

Clinical suspicion and detailed neurological examination followed by high-quality electrophysiological studies (EPS) must lead to an adequate preimaging localization of the lesion and narrowing of the imaging area. The use of high-resolution (3-T) MRI combined with gadolinium administration will allow adequate visualization of the internal anatomy of the nerve and help in differentiating other causes of neuropathy. In cases where the lesion is not recognized but clinical suspicion is high, possible errors must be assessed, including the EPS localization, area of imaging, MRI resolution, and slice thickness.