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Richard P. Menger, Jai Deep Thakur, Gary Jain and Anil Nanda

OBJECTIVE

Insurance preauthorization is used as a third-party tool to reduce health care costs. Given the expansion of managed care, the impact of the insurance preauthorization process in delaying health care delivery warrants investigation through a diversified neurosurgery practice.

METHODS

Data for 1985 patients were prospectively gathered over a 12-month period from July 1, 2014, until June 30, 2015. Information regarding attending, procedure, procedure type, insurance type, need for insurance approval, number of days for authorization, or insurance denial was obtained. Delay in authorization was defined as any wait period greater than 7 days. Some of the parameters were added retrospectively to enhance this study; hence, the total number of subjects may vary for different variables.

RESULTS

The most common procedure was back surgery with instrumentation (28%). Most of the patients had commercial insurance (57%) while Medicaid was the least common (1%). Across all neurosurgery procedures, insurance authorization, on average, was delayed 9 days with commercial insurance, 10.7 days with Tricare insurance, 8.5 days with Medicare insurance, 11.5 days with Medicaid, and 14.4 days with workers' compensation. Two percent of all patients were denied insurance preauthorization without any statistical trend or association. Of the 1985 patients, 1045 (52.6%) patients had instrumentation procedures. Independent of insurance type, instrumentation procedures were more likely to have delays in authorization (p = 0.001). Independent of procedure type, patients with Tricare (military) insurance were more likely to have a delay in approval for surgery (p = 0.02). Predictably, Medicare insurance was protective against a delay in surgery (p = 0.001).

CONCLUSIONS

Choice of insurance provider and instrumentation procedures were independent risk factors for a delay in insurance preauthorization. Neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data to deliver the best and most efficient care to our patients.

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David E. Connor Jr. and Anil Nanda

In the 1970s, the membrane of Liliequist became the accepted name for a small band of arachnoid membrane separating the interpeduncular and chiasmatic cisterns, making it one of the most recent of the universally accepted medical eponyms. The story of its discovery, however, cannot be told without a thorough understanding of the man responsible and his contribution to the growth of a specialty. Bengt Liliequist lived during what many would consider the Golden Age of neuroradiology. With his colleagues at the Serafimer Hospital in Stockholm, he helped set the standard for appropriate imaging of the CNS and contributed to more accurate localization of intracerebral as well as spinal lesions. The pneumoencephalographic discovery of the membrane that was to bear his name serves merely as a starting point for a career that spanned five decades and included the defense of two separate doctoral theses, the last of which occurred after his 80th birthday. Although the recognition of neuroradiology as a subspecialty did not occur in his home country of Sweden until after his retirement, and technological progress saw the obsolescence of the procedure that he had mastered, Dr. Liliequist's accomplishments and his contributions to the current understanding of neuroanatomy merit our continued praise.

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Anil Nanda, Shyamal C. Bir, Tanmoy K. Maiti, Subhas K. Konar, Symeon Missios and Bharat Guthikonda

OBJECTIVE

The clinical significance of the Simpson system for grading the extent of meningioma resection and its role as a predictor of the recurrence of World Health Organization (WHO) Grade I meningiomas have been questioned in the past, echoing changes in meningioma surgery over the years. The authors reviewed their experience in resecting WHO Grade I meningiomas and assessed the association between extent of resection, as evaluated using the Simpson classification, and recurrence-free survival (RFS) of patients after meningioma surgery.

METHODS

Clinical and radiological information for patients with WHO Grade I meningiomas who had undergone resective surgery over the past 20 years was retrospectively reviewed. Simpson and Shinshu grading scales were used to evaluate the extent of resection. Statistical analysis was conducted using Kaplan-Meier curves and Cox proportional-hazards regression.

RESULTS

Four hundred fifty-eight patients were eligible for analysis. Overall tumor recurrence rates for Simpson resection Grades I, II, III, and IV were 5%, 22%, 31%, and 35%, respectively. After Cox regression analysis, Simpson Grade I (extensive resection) was revealed as a significant predictor of RFS (p = 0.003). Patients undergoing Simpson Grade I and II resections showed significant improvement in RFS compared with patients undergoing Grade III and IV resections (p = 0.005). Extent of resection had a significant effect on recurrence rates for both skull base (p = 0.047) and convexity (p = 0.012) meningiomas. Female sex and a Karnofsky Performance Scale score > 70 were also identified as independent predictors of RFS after resection of WHO Grade I meningioma.

CONCLUSIONS

In this patient cohort, a significant association was noted between extent of resection and rates of tumor recurrence. In the authors' experience the Simpson grading system maintains its relevance and prognostic value and can serve an important role for patient education. Even though complete tumor resection is the goal, surgery should be tailored to each patient according to the risks and surgical morbidity.

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Anil Nanda, Jai Deep Thakur, Ashish Sonig and Symeon Missios

OBJECTIVE

Cavernous sinus meningiomas (CSMs) represent a cohort of challenging skull base tumors. Proper management requires achieving a balance between optimal resection, restoration of cranial nerve (CN) function, and maintaining or improving quality of life. The objective of this study was to assess the pre-, intra-, and postoperative factors related to clinical and neurological outcomes, morbidity, mortality, and tumor control in patients with CSM.

METHODS

A retrospective review of a single surgeon's experience with microsurgical removal of CSM in 65 patients between January 1996 and August 2013 was done. Sekhar's classification, modified Kobayashi grading, and the Karnofsky Performance Scale were used to define tumor extension, tumor removal, and clinical outcomes, respectively.

RESULTS

Preoperative CN dysfunction was evident in 64.6% of patients. CN II deficits were most common. The greatest improvement was seen for CN V deficits, whereas CN II and CN IV deficits showed the smallest degree of recovery. Complete resection was achieved in 41.5% of cases and was not significantly associated with functional CN recovery. Internal carotid artery encasement significantly limited the complete microscopic resection of CSM (p < 0.0001). Overall, 18.5% of patients showed symptomatic recurrence after their initial surgery (mean follow-up 60.8 months [range 3–199 months]). The use of adjuvant stereotactic radiosurgery (SRS) after microsurgery independently decreased the recurrence rate (p = 0.009; OR 0.036; 95% CI 0.003–0.430).

CONCLUSIONS

Modified Kobayashi tumor resection (Grades I–IIIB) was possible in 41.5% of patients. CN recovery and tumor control were independent of extent of tumor removal. The combination of resection and adjuvant SRS can achieve excellent tumor control. Furthermore, the use of adjuvant SRS independently decreases the recurrence rates of CSM.

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Shyamal C. Bir, Sudheer Ambekar, Sunil Kukreja and Anil Nanda

Julius Caesar Arantius is one of the pioneer anatomists and surgeons of the 16th century who discovered the different anatomical structures of the human body. One of his prominent discoveries is the hippocampus. At that time, Arantius originated the term hippocampus, from the Greek word for seahorse (hippos [“horse”] and kampos [“sea monster”]). Arantius published his description of the hippocampus in 1587, in the first chapter of his work titled De Humano Foetu Liber. Numerous nomenclatures of this structure, including “white silkworm,” “Ammon's horn,” and “ram's horn” were proposed by different scholars at that time. However, the term hippocampus has become the most widely used in the literature.

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David E. Connor Jr., Prashant Chittiboina and Anil Nanda

The authors trace the etymology and historical significance of galea or epicranial aponeurosis. In ancient Greece, galea referred to a helmet worn by soldiers, typically made of animal hide or leather. Throughout antiquity, physicians referred to all soft tissue between the skin and the skull as panniculus, a standard established by Galen of Pergamon. A manual of surgery in the Middle Ages referred to the entire scalp as a “great panicle that is called pericranium.” During the early Renaissance, Leonardo da Vinci famously and stylistically analogized the dissection of the cranium with the peeling of an onion. Not until 1724 would the tendinous sheath connecting the frontalis and occipitalis muscles be defined as “Galea tendinosa cranii.” By 1741, the convention of referring to the galea as an aponeurosis was well established.

Harvey Cushing's wartime experiences at Army Base Hospital No. 5 reinforced the surgical significance of the galea. Operative mortality was significantly diminished due to “closure of the wounds with buried sutures in the galea.” This operative nuance was then passed from teacher to pupil and has now become one of the tenets of modern neurosurgical practice.