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Jacob R. Lepard, Beverly C. Walters, and Curtis J. Rozzelle

OBJECTIVE

Neurosurgery, and particularly spine surgery, is among the most highly litigated medical specialties in the US, rendering the current malpractice climate of primary importance to spine surgeons nationwide. One of the primary methods of tort reform in the civil justice system is malpractice damage capitation (or “caps”); however, its efficacy is widely debated. The purpose of this article is to serve as a review for the practicing neurosurgeon, with particular emphasis on short- and long-term effects of damage caps and on the current debate regarding their utility, based on a systematic review of the literature.

METHODS

The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines for systematic review of observational studies were used in the design of the study. Multiple medical and legal online databases (MEDLINE, Scopus, EMBASE, and JSTOR) were queried using the key words “malpractice” and “damage capitation” for articles from 2000 to 2014. A total of 96 abstracts were screened for inclusion and exclusion criteria. Of these, 22 articles were reviewed in full and another 15 were excluded for study design or poor quality of data. Five more studies were added after cross-checking the bibliographies of the included articles. The resulting 12 articles were evaluated; relevant data were extracted using a standardized metric.

RESULTS

Five studies were found showing varying effects of capitation on physician availability, with only 1 of these specifically showing increased availability of neurosurgery and elective spine coverage in states with capitation. Four studies demonstrated that capitation overall succeeds in decreasing jury awards and frequency of claims filed. Last, 3 studies were found showing an overall decrease in malpractice premiums for states that passed damage capitation.

CONCLUSIONS

There is evidence in the literature showing that total and noneconomic damage capitation has the potential to improve the practice environment for neurosurgeons nationwide. Additionally, there are other factors that affect malpractice premium rates, such as the investment markets, which are not affected by these laws. All of these are important for spine surgeons to consider and be aware of in advocating for appropriate reform measures in their states.

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Nguyen Duc Lien, Dang Anh Tuan, Cao Vu Hung, Jacob R. Lepard, and Brandon G. Rocque

OBJECTIVE

The aim of this study was to evaluate postoperative seizure outcome in children with drug-resistant epilepsy not eligible for focal resection who underwent corpus callosotomy.

METHODS

The study included 16 patients undergoing corpus callosotomy between September 2015 and May 2018. Seizure semiology and frequency, psychomotor status, and video electroencephalography and imaging findings were evaluated for all patients.

RESULTS

Of the 16 patients who underwent callosotomy during the study period, 11 underwent complete callosotomy and 5 underwent anterior only. Seizure improvement greater than 75% was achieved in 37.5% of patients, and another 50% of patients had seizure improvement of 50%–75%. No sustained neurological deficits were observed in these patients. There were no significant complications. Duration of postoperative follow-up ranged from 12 to 44 months.

CONCLUSIONS

Corpus callosotomy is an effective treatment for selected patients with drug-resistant epilepsy not eligible for focal resection in resource-limited settings. Fostering and developing international epilepsy surgery centers should remain a high priority for the neurosurgical community at large.

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Jacob R. Lepard, Christopher D. Shank, Bonita S. Agee, Mark N. Hadley, and Beverly C. Walters

OBJECTIVE

The application of evidence-based medicine (EBM) has played an increasing role within neurosurgical education over the last several decades. The Accreditation Council for Graduate Medical Education (ACGME) has mandated that residents are now required to demonstrate academic productivity and mastery of EBM principles. The goal of this study was to assess how neurosurgery programs around the US are dealing with the challenges of fulfilling these program requirements from the ACGME in addition to standard neurosurgical education.

METHODS

A 20-question survey was developed and electronically delivered to residency program directors of the 110 ACGME-approved MD and DO training programs in the US. Data regarding journal club and critical appraisal skills, research requirements, and protected research time were collected. Linear regression was used to determine significant associations between these data and reported resident academic productivity.

RESULTS

Responses were received from 102 of the 110 (92.7%) neurosurgical training programs in the US. Ninety-eight programs (96.1%) confirmed a regularly scheduled journal club. Approximately half of programs (51.5%) indicated that the primary goal of their journal club was to promote critical appraisal skills. Only 58.4% of programs reported a formal EBM curriculum. In 57.4% of programs an annual resident publication requirement was confirmed. Multivariate regression models demonstrated that greater protected research time (p = 0.001), journal club facilitator with extensive training in research methods (p = 0.029), and earlier research participation during residency (p = 0.049) all increased the number of reported publications per resident.

CONCLUSIONS

Although specific measures are important, and should be tailored to the program, the overall training culture with faculty mentorship and provision of time and resources for research activity are probably the most important factors.

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Jacob R. Lepard, S. Hassan A. Akbari, Faizal Haji, Matthew C. Davis, William Harkness, and James M. Johnston

OBJECTIVE

Despite general enthusiasm for international collaboration within the organized neurosurgical community, establishing international partnerships remains challenging. The current study analyzes the initial experience of the InterSurgeon website in partnering surgeons from across the world to increase surgical collaboration.

METHODS

One year after the launch of the InterSurgeon website, data were collected to quantify the number of website visits, average session duration, total numbers of matches, and number of offers and requests added to the website each month. Additionally, a 15-question survey was designed and distributed to all registered members of the website.

RESULTS

There are currently 321 surgeon and institutional members of InterSurgeon representing 69 different countries and all global regions. At the time of the survey there were 277 members, of whom 76 responded to the survey, yielding a response rate of 27.4% (76/277). Twenty-five participants (32.9%) confirmed having either received a match email (12/76, 15.8%) or initiated contact with another user via the website (13/76, 17.1%). As expected, the majority of the collaborations were either between a high-income country (HIC) and a low-income country (LIC) (5/18, 27.8%) or between an HIC and a middle-income country (MIC) (9/18, 50%). Interestingly, there were 2 MIC-to-MIC collaborations (2/18, 11.1%) as well as 1 MIC-to-LIC (1/18, 5.6%) and 1 LIC-to-LIC partnership. At the time of response, 6 (33.3%) of the matches had at least resulted in initial contact via email or telephone. One of the partnerships had involved face-to-face interaction via video conference. A total of 4 respondents had traveled internationally to visit their partner’s institution.

CONCLUSIONS

Within its first year of launch, the InterSurgeon membership has grown significantly. The partnerships that have already been formed involve not only international visits between HICs and low- to middle-income countries (LMICs), but also telecollaboration and inter-LMIC connections that allow for greater exchange of knowledge and expertise. As membership and site features grow to include other surgical and anesthesia specialties, membership growth and utilization is expected to increase rapidly over time according to social network dynamics.

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Saniya Mediratta, Jacob R. Lepard, Ernest J. Barthélemy, Jacquelyn Corley, and Kee B. Park

OBJECTIVE

Delays along the neurosurgical care continuum are associated with poor outcomes and are significantly greater in low- to middle-income countries (LMICs), with timely access to neurotrauma care remaining one of the most significant unmet neurosurgical needs worldwide. Using Lancet Global Surgery metrics and the Three Delays framework, the authors of this study aimed to identify and characterize the most significant barriers to the delivery of neurotrauma care in LMICs from the perspective of local neurotrauma providers.

METHODS

The authors conducted a cross-sectional study through the dissemination of a web-based survey to neurotrauma providers across all World Health Organization geographic regions. Responses were analyzed with descriptive statistics and Kruskal-Wallis testing, using World Bank data to provide estimates of populations at risk.

RESULTS

Eighty-two (36.9%) of 222 neurosurgeons representing 47 countries participated in the survey. It was estimated that 3.9 billion people lack access to neurotrauma care within 2 hours. Nearly 3.4 billion were estimated to be at risk for impoverishing expenditure and 2.9 billion were at risk of catastrophic expenditure as a result of paying for care for neurotrauma injuries. Delays in seeking care were rated as slightly common (p < 0.001), those in reaching care were very common (p < 0.001), and those in receiving care were slightly common (p < 0.05). The most significant causes for delays were associated with reaching care, including geographic distance from a facility, lack of ambulance service, and lack of finances for travel. All three delays were correlated to income classification and geographic region.

CONCLUSIONS

While expanding the global neurosurgical workforce is of the utmost importance, the study data suggested that it may not be entirely sufficient in gaining access to care for the emergent neurosurgical patient. Significant income and region-specific variability exists with regard to barriers to accessing neurotrauma care. Highlighting these barriers and quantifying worldwide access to neurotrauma care using metrics from the Lancet Commission on Global Surgery provides essential insight for future initiatives aiming to strengthen global neurotrauma systems.

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Anthony M. DiGiorgio, Michael S. Virk, and Praveen V. Mummaneni

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Nicholas B. Rossi, Nickalus R. Khan, Tamekia L. Jones, Jacob Lepard, Joseph H. McAbee, and Paul Klimo Jr.

OBJECT

Ventricular shunts for pediatric hydrocephalus continue to be plagued with high failure rates. Reported risk factors for shunt failure are inconsistent and controversial. The raw or global shunt revision rate has been the foundation of several proposed quality metrics. The authors undertook this study to determine risk factors for shunt revision within their own patient population.

METHODS

In this single-center retrospective cohort study, a database was created of all ventricular shunt operations performed at the authors’ institution from January 1, 2010, through December 2013. For each index shunt surgery, demographic, clinical, and procedural variables were assembled. An “index surgery” was defined as implantation of a new shunt or the revision or augmentation of an existing shunt system. Bivariate analyses were first performed to evaluate individual effects of each independent variable on shunt failure at 90 days and at 180 days. A final multivariate model was chosen for each outcome by using a backward model selection approach.

RESULTS

There were 466 patients in the study accounting for 739 unique (“index”) operations, for an average of 1.59 procedures per patient. The median age for the cohort at the time of the first shunt surgery was 5 years (range 0–35.7 years), with 53.9% males. The 90- and 180-day shunt failure rates were 24.1% and 29.9%, respectively. The authors found no variable—demographic, clinical, or procedural—that predicted shunt failure within 90 or 180 days.

CONCLUSIONS

In this study, none of the risk factors that were examined were statistically significant in determining shunt failure within 90 or 180 days. Given the negative findings and the fact that all other risk factors for shunt failure that have been proposed in the literature thus far are beyond the control of the surgeon (i.e., nonmodifiable), the use of an institution’s or individual’s global shunt revision rate remains questionable and needs further evaluation before being accepted as a quality metric.

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Jacob R. Lepard, Kathrin D. Zimmerman, Anastasia A. Arynchyna, Jessica A. Gutman, Arsalaan A. Salehani, Brandon G. Rocque, and Curtis J. Rozzelle

OBJECTIVE

Surgical treatment of herniated lumbar disc (HLD) remains rare in children. The purpose of this study was to evaluate for potential disease risk factors leading to surgery based on a large single-center experience.

METHODS

Data for all patients who had undergone surgical treatment for HLD between December 2008 and December 2016 at a single pediatric tertiary care referral center were collected and compared to data for a healthy control population obtained through a Youth Risk Behavior Surveillance System (YRBSS) survey in order to determine relevant disease risk factors. Univariate and multivariate logistic regression were used to determine the effect of potential risk factors.

RESULTS

Twenty-seven patients in the disease cohort and 5212 healthy controls from the general population were included in the risk factor analysis. The mean body mass index was significantly higher in the disease population (30.2 vs 24.0 kg/m2, p < 0.0001). Children who had undergone microdiscectomy were more likely to be obese (OR 7.4, 95% CI 3.46–15.8, p < 0.001). No association was found between lumbar microdiscectomy and sports participation (OR 1.0, 95% CI −0.002 to 0.005, p = 0.37).

CONCLUSIONS

Microdiscectomy remains a viable and safe option in the setting of failed conservative management for pediatric HLD. Childhood obesity is a risk factor for HLD and many other diseases, which increases its importance as a public health priority.

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Jacob R. Lepard, Esther Dupépé, Matthew Davis, Jennifer DeWolfe, Bonita Agee, J. Nicole Bentley, and Kristen Riley

OBJECTIVE

Invasive monitoring has long been utilized in the evaluation of patients for epilepsy surgery, providing localizing information to guide resection. Stereoelectroencephalography (SEEG) was introduced at the authors’ level 4 epilepsy surgery program in 2013, with responsive neurostimulation (RNS) becoming available the following year. The authors sought to characterize patient demographics and epilepsy-related variables before and after SEEG introduction to understand whether differences emerged in their patient population. This information will be useful in understanding how SEEG, possibly in conjunction with RNS availability, may have changed practice patterns over time.

METHODS

This is a retrospective cohort study of consecutive patients who underwent surgery for epilepsy from 2006 to 2018, comprising 7 years before and 5 years after the introduction of SEEG. The authors performed univariate analyses of patient characteristics and outcomes and used generalized estimating equations logistic regression for predictive analysis.

RESULTS

A total of 178 patients were analyzed, with 109 patients in the pre-SEEG cohort and 69 patients in the post-SEEG cohort. In the post-SEEG cohort, more patients underwent invasive monitoring for suspected bilateral seizure onsets (40.6% vs 22.0%, p = 0.01) and extratemporal seizure onsets (68.1% vs 8.3%, p < 0.0001). The post-SEEG cohort had a higher proportion of patients with seizures arising from eloquent cortex (14.5% vs 0.9%, p < 0.001). Twelve patients underwent RNS insertion in the post-SEEG group versus none in the pre-SEEG group. Fewer patients underwent resection in the post-SEEG group (55.1% vs 96.3%, p < 0.0001), but there was no significant difference in rates of seizure freedom between cohorts for those patients having undergone a follow-up resection (53.1% vs 59.8%, p = 0.44).

CONCLUSIONS

These findings demonstrate that more patients with suspected bilateral, eloquent, or extratemporal epilepsy underwent invasive monitoring after adoption of SEEG. This shift occurred coincident with the adoption of RNS, both of which likely contributed to increased patient complexity. The authors conclude that their practice now considers invasive monitoring for patients who likely would not previously have been candidates for surgical investigation and subsequent intervention.

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Jacob R. Lepard, Irene Kim, Anastasia Arynchyna, Sean M. Lew, Robert J. Bollo, Brent R. O’Neill, M. Scott Perry, David Donahue, Matthew D. Smyth, and Jeffrey Blount

OBJECTIVE

Pediatric stereoelectroencephalography (SEEG) has been increasingly performed in the United States, with published literature being limited primarily to large single-center case series. The purpose of this study was to evaluate the experience of pediatric epilepsy centers, where the technique has been adopted in the last several years, via a multicenter case series studying patient demographics, outcomes, and complications.

METHODS

A retrospective cohort methodology was used based on the STROBE criteria. ANOVA was used to evaluate for significant differences between the means of continuous variables among centers. Dichotomous outcomes were assessed between centers using a univariate and multivariate logistic regression.

RESULTS

A total of 170 SEEG insertion procedures were included in the study from 6 different level 4 pediatric epilepsy centers. The mean patient age at time of SEEG insertion was 12.3 ± 4.7 years. There was no significant difference between the mean age at the time of SEEG insertion between centers (p = 0.3). The mean number of SEEG trajectories per patient was 11.3 ± 3.6, with significant variation between centers (p < 0.001). Epileptogenic loci were identified in 84.7% of cases (144/170). Patients in 140 cases (140/170, 82.4%) underwent a follow-up surgical intervention, with 47.1% (66/140) being seizure free at a mean follow-up of 30.6 months. An overall postoperative hemorrhage rate of 5.3% (9/170) was noted, with patients in 4 of these cases (4/170, 2.4%) experiencing a symptomatic hemorrhage and patients in 3 of these cases (3/170, 1.8%) requiring operative evacuation of the hemorrhage. There were no mortalities or long-term complications.

CONCLUSIONS

As the first multicenter case series in pediatric SEEG, this study has aided in establishing normative practice patterns in the application of a novel surgical technique, provided a framework for anticipated outcomes that is generalizable and useful for patient selection, and allowed for discussion of what is an acceptable complication rate relative to the experiences of multiple institutions.