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Hasan A. Zaidi, Kristina Chapple and Andrew S. Little


Treatment of craniopharyngiomas is one of the most demanding and controversial neurosurgical procedures performed. The authors sought to determine the factors associated with hospital charges and fees for craniopharyngioma treatment to identify possible opportunities for improving the health care economics of inpatient care.


The authors analyzed the hospital discharge database of the Nationwide Inpatient Sample (NIS) covering the period from 2007 through 2011 to examine national treatment trends for adults (that is, those older than 18 years) who had undergone surgery for craniopharyngioma. To predict the drivers of in-hospital charges, a multistep regression model was developed that accounted for patient demographics, acuity measures, comorbidities, hospital characteristics, and complications.


The analysis included 606 patients who underwent resection of craniopharyngioma; 353 resections involved a transsphenoidal approach (58%) and 253 a transfrontal approach (42%). The mean age (± SD) of patients was 47.7 ± 16.3 years. The average hospital length of stay (LOS) was 7.6 ± 9 days. The mean hospital charge (± SD) was $92,300 ± $83,356. In total, 48% of the patients experienced postoperative diabetes insipidus or an electrolyte abnormality. A multivariate regression model demonstrated that LOS, hospital volume for the selected procedure, the surgical approach, postoperative complications, comorbidities, and year of surgery were all significant predictors of in-hospital charges. The statistical model accounted for 54% of the variance in in-hospital charge.


This analysis of inpatient hospital charges in patients undergoing craniopharyngioma surgery identified key drivers of charges in the perioperative period. Prospective studies designed to evaluate the long-term resource utilization in this complex patient population would be a useful future direction.

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Seungwon Yoon, Michael A. Mooney, Michael A. Bohl, John P. Sheehy, Peter Nakaji, Andrew S. Little and Michael T. Lawton


With drastic changes to the health insurance market, patient cost sharing has significantly increased in recent years. However, the patient financial burden, or out-of-pocket (OOP) costs, for surgical procedures is poorly understood. The goal of this study was to analyze patient OOP spending in cranial neurosurgery and identify drivers of OOP spending growth.


For 6569 consecutive patients who underwent cranial neurosurgery from 2013 to 2016 at the authors’ institution, the authors created univariate and multivariate mixed-effects models to investigate the effect of patient demographic and clinical factors on patient OOP spending. The authors examined OOP payments stratified into 10 subsets of case categories and created a generalized linear model to study the growth of OOP spending over time.


In the multivariate model, case categories (craniotomy for pain, tumor, and vascular lesions), commercial insurance, and out-of-network plans were significant predictors of higher OOP payments for patients (all p < 0.05). Patient spending varied substantially across procedure types, with patients undergoing craniotomy for pain ($1151 ± $209) having the highest mean OOP payments. On average, commercially insured patients spent nearly twice as much in OOP payments as the overall population. From 2013 to 2016, the mean patient OOP spending increased 17%, from $598 to $698 per patient encounter. Commercially insured patients experienced more significant growth in OOP spending, with a cumulative rate of growth of 42% ($991 in 2013 to $1403 in 2016).


Even after controlling for inflation, case-mix differences, and partial fiscal periods, OOP spending for cranial neurosurgery patients significantly increased from 2013 to 2016. The mean OOP spending for commercially insured neurosurgical patients exceeded $1400 in 2016, with an average annual growth rate of 13%. As patient cost sharing in health insurance plans becomes more prevalent, patients and providers must consider the potential financial burden for patients receiving specialized neurosurgical care.

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Ali M. Elhadi, Samuel Kalb, Luis Perez-Orribo, Andrew S. Little, Robert F. Spetzler and Mark C. Preul

The field of anatomy, one of the most ancient sciences, first evolved in Egypt. From the Early Dynastic Period (3100 bc) until the time of Galen at the end of the 2nd century ad, Egypt was the center of anatomical knowledge, including neuroanatomy. Knowledge of neuroanatomy first became important so that sacred rituals could be performed by ancient Egyptian embalmers during mummification procedures. Later, neuroanatomy became a science to be studied by wise men at the ancient temple of Memphis. As religious conflicts developed, the study of the human body became restricted. Myths started to replace scientific research, squelching further exploration of the human body until Alexander the Great founded the city of Alexandria. This period witnessed a revolution in the study of anatomy and functional anatomy. Herophilus of Chalcedon, Erasistratus of Chios, Rufus of Ephesus, and Galen of Pergamon were prominent physicians who studied at the medical school of Alexandria and contributed greatly to knowledge about the anatomy of the skull base. After the Royal Library of Alexandria was burned and laws were passed prohibiting human dissections based on religious and cultural factors, knowledge of human skull base anatomy plateaued for almost 1500 years. In this article the authors consider the beginning of this journey, from the earliest descriptions of skull base anatomy to the establishment of basic skull base anatomy in ancient Egypt.