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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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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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Richard Menger, Michael Wolf, Jai Deep Thakur, Anil Nanda and Anthony Martino

In 1961, President John F. Kennedy declared that the United States would send a man to the moon and safely bring him home before the end of the decade. Astronaut Michael Collins was one of those men. He flew to the moon on the historic flight of Apollo 11 while Neil Armstrong and Buzz Aldrin walked on its surface. However, this was not supposed to be the case.

Astronaut Collins was scheduled to fly on Apollo 8. While training, in 1968, he started developing symptoms of cervical myelopathy. He underwent evaluation at Wilford Hall Air Force Hospital in San Antonio and was noted to have a C5–6 disc herniation and posterior osteophyte on myelography. Air Force Lieutenant General (Dr.) Paul W. Myers performed an anterior cervical discectomy with placement of iliac bone graft. As a result, Astronaut James Lovell took his place on Apollo 8 flying the uncertain and daring first mission to the moon. This had a cascading effect on the rotation of astronauts, placing Michael Collins on the Apollo 11 flight that first landed men on the moon. It also placed Astronaut James Lovell in a rotation that exposed him to be the Commander of the fateful Apollo 13 flight.

Here, the authors chronicle the history of Astronaut Collins’ anterior cervical surgery and the impact of his procedure on the rotation of astronaut flight selection, and they review the pivotal historic nature of the Apollo 8 spaceflight. The authors further discuss the ongoing issue of cervical disc herniation among astronauts.

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Ashish Sonig, Jai Deep Thakur, Prashant Chittiboina, Imad Saeed Khan and Anil Nanda

Object

Various factors have been reported in literature to be associated with the development of posttraumatic meningitis. There is a paucity of data regarding skull fractures and facial fractures leading to CSF leaks and their association with the development of meningitis. The primary objective of this study was to analyze the US Nationwide Inpatient Sample (NIS) database to elucidate the factors associated with the development of posttraumatic meningitis. A secondary goal was to analyze the overall hospitalization cost related to posttraumatic meningitis and factors associated with that cost.

Methods

The NIS database was analyzed to identify patients admitted to hospitals with a diagnosis of head injury from 2005 through 2009. This data set was analyzed to assess the relationship of various clinical parameters that may affect the development of posttraumatic meningitis using binary logistic regression models. Additionally, the overall hospitalization cost for the head injury patients who did not undergo any neurosurgical intervention was further categorized into quartile groups, and a regression model was created to analyze various factors responsible for escalating the overall cost of the hospital stay.

Results

A total of 382,267 inpatient admissions for head injury were analyzed for the 2005–2009 period. Meningitis was reported in 0.2% of these cases (708 cases). Closed skull base fractures, open skull base fractures, cranial vault fractures, and maxillofacial fractures were reported in 20,524 (5.4%), 1089 (0.3%), 5064 (1.3%), and 88,649 (23.2%) patients, respectively. Among these patients with fractures, meningitis was noted in 0.17%, 0.18%, 0.05%, and 0.10% admissions, respectively. Cerebrospinal fluid rhinorrhea was reported in 453 head injury patients (0.1%) and CSF otorrhea in 582 (0.2%). Of the patients reported to have CSF rhinorrhea, 35 (7.7%) developed meningitis, whereas in the cohort with CSF otorrhea, 15 patients (2.6%) developed meningitis. Cerebrospinal fluid rhinorrhea (p < 0.001, OR 22.8, 95% CI 15.6–33.3), CSF otorrhea (p < 0.001, OR 9.2, 95% CI 5.2–16.09), and major neurosurgical procedures (p < 0.001, OR 5.6, 95% CI 4.8–6.5) were independent predictors of meningitis. Further, CSF rhinorrhea (p < 0.001, OR 2.0, 95% CI 1.6–2.7), CSF otorrhea (p < 0.001, OR 2.3, 95% CI 1.9–2.7), and posttraumatic meningitis (p < 0.001, OR 3.1, 95% CI 2.5–3.8) were independent factors responsible for escalating the cost of head injury in cases not requiring any major neurosurgical intervention.

Conclusions

Cerebrospinal fluid rhinorrhea and CSF otorrhea are independent predictors of posttraumatic meningitis. Furthermore, meningitis and CSF fistulas may independently lead to significantly increased cost of hospitalization in head injury patients not undergoing any major neurosurgical intervention.

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Ashish Sonig, Imad Saeed Khan, Rishi Wadhwa, Jai Deep Thakur and Anil Nanda

Object

Hospitalization cost and patient outcome after acoustic neuroma surgery depend on several factors. There is a paucity of data regarding the relationship between demographic features such as age, sex, race, insurance status, and patient outcome. Apart from demographic factors, there are several hospital-related factors and regional issues that can affect outcomes and hospital costs. To the authors' knowledge, no study has investigated the issue of regional disparity across the country in terms of cost of hospitalization and discharge disposition.

Methods

The authors analyzed the Nationwide Inpatient Sample (NIS) database over the years 2005–2009. Several variables were analyzed from the database, including patient demographics, comorbidities, and surgical complications. Hospital variables, such as bedsize, rural/urban location, teaching status, federal or private ownership, and the region, were also examined. Patient outcome and increased hospitalization costs were the dependent variables studied.

Results

A total of 2589 admissions from 242 hospitals were analyzed from the NIS data over the years 2005–2009. The mean age was 48.99 ± 13.861 years (± SD), and 304 (11.7%) of the patients were older than 65 years. The cumulative cost incurred by the hospitals from 2005 to 2009 was $948.77 million. The mean expenditure per admission was $76,365.09 ± $58,039.93. The mean total charges per admission rose from $59,633.00 in 2005 to $97,370.00 in 2009. The factors that predicted most significantly with other than routine (OTR) disposition outcome were age older than 65 years (OR 2.22, 95% CI 1.411–3.518; p < 0.001), aspiration pneumonia (OR 16.085, 95% CI 4.974–52.016; p < 0.001), and meningitis (OR 11.299, 95% CI 3.126–40.840; p < 0.001). When compared with patients with Medicare and Medicaid, patients with private insurance had a protective effect against OTR disposition outcome. Higher comorbidities predicted independently for OTR disposition outcome (OR 1.409, 95% CI 1.072–1.852; p = 0.014). The West region predicted negatively for OTR disposition outcome. Large hospitals were independently associated with higher hospital charges (OR 4.269, 95% CI 3.106–5.867; p < 0.001). The West region had significantly higher (p < 0.001) mean hospital charges than the other regions. Patient factors such as meningitis and aspiration pneumonia were strong independent predictors of increased hospital charges (p < 0.001). Higher comorbidities (OR 1.297, 95% CI 1.036–1.624; p = 0.023) and presence of neurofibromatosis Type 2 (OR 2.341, 95% CI 1.479–3.707; p < 0.001) were associated with higher hospital charges.

Conclusions

The authors' study shows that several factors can affect patient outcome and hospital charges for patients who have undergone acoustic neuroma surgery. Factors such as younger age, higher ZIP code income, less comorbidity, private insurance, elective surgery, and the West region predicted for better disposition outcome. However, the West region, higher comorbidities, and weekend admissions were associated with higher hospitalization costs.

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Imad Saeed Khan, Ashish Sonig, Jai Deep Thakur, Papireddy Bollam and Anil Nanda

Object

Transforaminal lumbar interbody fusion (TLIF) has been increasingly used to treat degenerative spine disease, including that in patients in whom earlier decompressive procedures have failed. Reexploration in these cases is always challenging and is thought to pose a higher risk of complications. To the best of the authors' knowledge, there are no current studies specifically analyzing the effects of previous lumbar decompressive surgeries on the complication rates of open TLIF.

Methods

The authors performed a retrospective study of surgeries performed by a single surgeon. A total of 187 consecutive patients, in whom the senior author (A.N.) had performed open TLIF between January 2007 and January 2011, met the inclusion criteria. The patients were divided into two groups (primary and revision TLIF) for the comparison of perioperative complications.

Results

Overall, the average age of the patients was 49.7 years (range 18–80 years). Of the 187 patients, 73 patients had no history of lumbar surgery and 114 were undergoing revision surgery. Fifty-four patients (28.9%) had a documented complication intraoperatively or postoperatively. There was no difference in the rate on perioperative complications between the two groups (overall, medical, wound related, inadvertent dural tears [DTs], or neural injury). Patients who had undergone more than one previous lumbar surgery were, however, more likely to have suffered from DTs (p = 0.054) and neural injuries (p = 0.007) compared with the rest.

Conclusions

In the hands of an experienced surgeon, revision open TLIF does not necessarily increase the risk of perioperative complications compared with primary TLIF. Two or more previous lumbar decompressive procedures, however, increase the risk of inadvertent DTs and neural injury.

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Cedric D. Shorter, David E. Connor Jr., Jai Deep Thakur, Gale Gardner, Anil Nanda and Bharat Guthikonda

Object

Methods for repairing middle fossa CSF (MFCSF) leaks have varied and yielded mixed results. The objective of this study was to evaluate the safety and durability of the authors' repair technique using a novel combination of 3 synthetic materials.

Methods

The authors performed a retrospective case review of patients treated for CSF leaks between January 2009 and September 2011. Eight patients were found to have undergone middle fossa craniotomies for CSF leaks. Inclusion criteria for the study included age greater than 18 years, neuroimaging-documented temporal bone defect, and symptoms consistent with CSF leaks or gross CSF otorrhea. Seven patients, 3 men and 4 women, met the inclusion criteria, and their charts were reviewed. Hydroxyapatite cement, collagen-based dural substitute matrix, and polyethylene glycol hydrogel sealant were used in all patients for the repair.

Results

In all patients the MFCSF leaks were successfully repaired. Initial presenting symptoms included CSF otorrhea in 4 patients (57.1%), hearing loss in 3 (42.9%), and CSF rhinorrhea in 1 (14.3%). The mean follow-up duration was 12 months (range 5–33 months). In 1 patient an epidural hematoma developed at the operative site on postoperative Day 2, and in another patient a superficial wound dehiscence occurred on postoperative Day 48. During the follow-up period, the authors found no evidence of wound infections, neurovascular damage, or CSF leakage requiring reoperation.

Conclusions

The middle fossa approach involving a combination of hydroxyapatite cement, collagen-based dural substitute matrix, and polyethylene glycol hydrogel sealant is a safe, effective method for repairing MFCSF leaks. The combination of synthetic materials provides an alternative to existing materials for skull base surgeons.

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Jai Deep Thakur, Imad Saeed Khan, Cedric D. Shorter, Ashish Sonig, Gale L. Gardner, Bharat Guthikonda and Anil Nanda

Object

The goal of this study was to perform a systematic quantitative comparison of the surgical outcomes between cystic vestibular schwannomas (CVSs) and solid vestibular schwannomas (SVSs).

Methods

A review of English-language literature published between 1990 and 2011 was performed using various search engines including PubMed, Google Scholar, and the Cochrane database. Only studies that reported surgical results of CVSs in comparison with SVSs were included in the analysis. The primary end point of this study was surgical outcomes, defined by the following: 1) facial nerve outcomes at latest follow-up; 2) mortality rates; or 3) non–facial nerve complication index. Secondary end points included extent of resection and brainstem adherence.

Results

Nine studies comprising 428 CVSs and 1287 SVSs were included in the study. The mean age of patients undergoing surgery was 48.3 ± 6.75 and 47.1 ± 9 years for CVSs and SVSs, respectively (p = 0.8). The mean tumor diameter for CVSs was 3.9 ± 0.84 cm and that for SVSs was 3.7 ± 1.2 cm (p = 0.7). There was no significant difference in the extent of resection among CVSs and SVSs (81.2% vs 80.7%, p = 0.87) Facial nerve outcomes were significantly better in the cohort of patients with SVSs than in those with CVSs (52.1% vs 39%, p = 0.0001). The perioperative mortality rates for CVSs and SVSs were not significantly different (3% and 3.8%, respectively; p = 0.6). No significant difference was noted between the cumulative non–facial nerve complication rate (including mortality) among patients with CVSs and SVSs (24.5% and 25.6%, respectively; p = 0.75)

Conclusions

Facial nerve outcomes are worse in patients undergoing resection for CVSs than in patients undergoing resection for SVSs. There were no significant differences in the extent of resection or postoperative morbidity and mortality rates between the cohorts of patients with vestibular schwannomas.

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Jai Deep Thakur, Ashish Sonig, Prashant Chittiboina, Imad Saeed Khan, Rishi Wadhwa and Anil Nanda

Humphrey Ridley, M.D. (1653–1708), is a relatively unknown historical figure, belonging to the postmedieval era of neuroanatomical discovery. He was born in the market town of Mansfield, 14 miles from the county of Nottinghamshire, England. After studying at Merton College, Oxford, he pursued medicine at Leiden University in the Netherlands. In 1688, he was incorporated as an M.D. at Cambridge. Ridley authored the first original treatise in English language on neuroanatomy, The Anatomy of the Brain Containing its Mechanisms and Physiology: Together with Some New Discoveries and Corrections of Ancient and Modern Authors upon that Subject.

Ridley described the venous anatomy of the eponymous circular sinus in connection with the parasellar compartment. His methods were novel, unique, and effective. To appreciate the venous anatomy, he preferred to perform his anatomical dissections on recently executed criminals who had been hanged. These cadavers had considerable venous engorgement, which made the skull base venous anatomy clearer. To enhance the appearance of the cerebral vasculature further, he used tinged wax and quicksilver in the injections. He set up experimental models to answer questions definitively, in proving that the arachnoid mater is a separate meningeal layer. The first description of the subarachnoid cisterns, blood-brain barrier, and the fifth cranial nerve ganglion with its branches are also attributed to Ridley.

This historical vignette revisits Ridley's life and academic work that influenced neuroscience and neurosurgical understanding in its infancy. It is unfortunate that most of his novel contributions have gone unnoticed and uncited. The authors hope that this article will inform the neurosurgical community of Ridley's contributions to the field of neurosurgery.

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Richard P. Menger, David E. Connor Jr., Jai Deep Thakur, Ashish Sonig, Elainea Smith, Bharat Guthikonda and Anil Nanda

Object

Complications following lumboperitoneal (LP) shunting have been reported in 18% to 85% of cases. The need for multiple revision surgeries, development of iatrogenic Chiari malformation, and frequent wound complications have prompted many to abandon this procedure altogether for the treatment of idiopathic benign intracranial hypertension (pseudotumor cerebri), in favor of ventriculoperitoneal (VP) shunting. A direct comparison of the complication rates and health care charges between first-choice LP versus VP shunting is presented.

Methods

The Nationwide Inpatient Sample database was queried for all patients with the diagnosis of benign intracranial hypertension (International Classification of Diseases, Ninth Revision, code 348.2) from 2005 to 2009. These data were stratified by operative intervention, with demographic and hospitalization charge data generated for each.

Results

A weighted sample of 4480 patients was identified as having the diagnosis of idiopathic intracranial hypertension (IIH), with 2505 undergoing first-time VP shunt placement and 1754 undergoing initial LP shunt placement. Revision surgery occurred in 3.9% of admissions (n = 98) for VP shunts and in 7.0% of admissions (n = 123) for LP shunts (p < 0.0001). Ventriculoperitoneal shunts were placed at teaching institutions in 83.8% of cases, compared with only 77.3% of first-time LP shunts (p < 0.0001). Mean hospital length of stay (LOS) significantly differed between primary VP (3 days) and primary LP shunt procedures (4 days, p < 0.0001). The summed charges for the revisions of 92 VP shunts ($3,453,956) and those of the 6 VP shunt removals ($272,484) totaled $3,726,352 over 5 years for the study population. The summed charges for revision of 70 LP shunts ($2,229,430) and those of the 53 LP shunt removals ($3,125,569) totaled $5,408,679 over 5 years for the study population.

Conclusions

The presented results appear to call into question the selection of LP shunt placement as primary treatment for IIH, as this procedure is associated with a significantly greater likelihood of need for shunt revision, increased LOS, and greater overall charges to the health care system.