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Symeon Missios and Kimon Bekelis

OBJECTIVE

Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection.

METHODS

A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score–adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level.

RESULTS

Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41–0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40–0.96) and a propensity score–adjusted model (OR 0.64, 95% CI 0.41–0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed.

CONCLUSIONS

Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

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Symeon Missios and Kimon Bekelis

OBJECTIVE

The accuracy of public reporting in health care is an issue of debate. The authors investigated the association of patient satisfaction measures from a public reporting platform with objective outcomes for patients undergoing spine surgery.

METHODS

The authors performed a cohort study involving patients undergoing elective spine surgery from 2009 to 2013 who were registered in the New York Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. A mixed-effects regression analysis, controlling for clustering at the hospital level, was used to investigate the association of patient satisfaction metrics with outcomes.

RESULTS

During the study period, 160,235 patients underwent spine surgery. Using a mixed-effects multivariable regression analysis, the authors demonstrated that undergoing elective spine surgery in hospitals with a higher percentage of patient-assigned high satisfaction scores was not associated with a decreased rate of discharge to rehabilitation (OR 0.77, 95% CI 0.57–1.06), mortality (OR 0.96, 95% CI 0.90–1.01), or hospitalization charges (β 0.04, 95% CI −0.16 to 0.23). However, it was associated with decreased length of stay (LOS; β −0.19, 95% CI −0.33 to −0.05). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others.

CONCLUSIONS

Merging a comprehensive all-payer cohort of spine surgery patients in New York state with data from the CMS Hospital Compare website, the authors were not able to demonstrate an association of improved performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, and hospitalization charges. Increased patient satisfaction was associated with decreased LOS.

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Symeon Missios, Kimon Bekelis and Gene H. Barnett

Laser interstitial thermal therapy (LITT) is a minimally invasive technique for treating intracranial tumors, originally introduced in 1983. Its use in neurosurgical procedures was historically limited by early technical difficulties related to the monitoring and control of the extent of thermal damage. The development of magnetic resonance thermography and its application to LITT have allowed for real-time thermal imaging and feedback control during laser energy delivery, allowing for precise and accurate provision of tissue hyperthermia. Improvements in laser probe design, surgical stereotactic targeting hardware, and computer monitoring software have accelerated acceptance and clinical utilization of LITT as a neurosurgical treatment alternative. Current commercially available LITT systems have been used for the treatment of neurosurgical soft-tissue lesions, including difficult to access brain tumors, malignant gliomas, and radiosurgery-resistant metastases, as well as for the ablation of such lesions as epileptogenic foci and radiation necrosis. In this review, the authors aim to critically analyze the literature to describe the advent of LITT as a neurosurgical, laser excision tool, including its development, use, indications, and efficacy as it relates to neurosurgical applications.

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Kimon Bekelis, Symeon Missios and Robert J. Spinner

OBJECT

Despite the growing epidemic of falls, the true incidence of peripheral nerve injuries (PNIs) in this patient population remains largely unknown.

METHODS

The authors performed a retrospective cohort study of 839,210 fall-injured patients who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011 and fulfilled the inclusion criteria. Regression techniques were used to investigate the association of demographic and socioeconomic factors with the rate of PNIs in this patient population. The association of age with the incidence of PNIs was also investigated.

RESULTS

Overall, 3151 fall-injured patients (mean age 39.1 years, 33.3% females) sustained a PNI (0.4% of all falls). The respective incidence of PNIs was 2.7 per 1000 patients for ground-level falls, 4.9 per 1000 patients for multilevel falls, and 4.5 per 1000 patients for falls involving force. This demonstrated a rapid increase in the first 2 decades of life, with a maximum rate of 1.1% of all falls in the 3rd decade, followed by a slower decline and eventual plateau in the 7th decade. In a multivariable analysis, the association of PNIs with age followed a similar pattern with patients 20–29 years of age, demonstrating the highest association (OR 2.34 [95% CI 2.0–2.74] in comparison with the first decade of life). Falls involving force (OR 1.25 [95% CI 1.14–1.37] in comparison with multilevel falls) were associated with a higher incidence of PNIs. On the contrary, female sex (OR 0.87 [95% CI 0.80–0.84]) and ground-level falls (OR 0.79 [95% CI 0.72–0.86]) were associated with a lower rate of PNIs.

CONCLUSIONS

Utilizing a comprehensive national database, the authors demonstrated that PNIs are more common than previously described in fall-injured patients and identified their age distribution. These injuries are associated with young adults and falls of high kinetic energy.

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Atman Desai, Kimon Bekelis and Kadir Erkmen

Effective surgical obliteration of spinal dural arteriovenous fistulas (DAVFs) traditionally requires laminectomy or hemilaminectomy to allow intradural exposure and occlusion of the draining vein. The authors present successful treatment of a spinal DAVF by using a tubular retractor system to provide minimally invasive exposure at the L5–S1 level adequate for both microsurgical treatment and intraoperative indocyanine green angiography.

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Symeon Missios, Kimon Bekelis and David W. Roberts

Paul of Aegina (625–690 AD) was born on the island of Aegina and was one of the most prominent physician-writers of the Byzantine Empire. His work Epitome of Medicine, comprised of 7 books, was a comprehensive compendium of the medical and surgical knowledge of his time and was subsequently translated into multiple languages. Paul of Aegina made valuable contributions to neurosurgical subjects and described procedures for the treatment of nerve injuries, hydrocephalus, and fractures of the skull and spine. His work combined the ancient knowledge of Hippocrates and Galen with contemporary medical observations and served as a bridge between Byzantine and Arabic medicine. He is considered to be one of the great ancient Greek medical writers and his work has influenced the subsequent evolution of Western European and Arab medicine. This paper provides an account of his contribution to the management of neurosurgical pathologies during the Byzantine era, as described in his medical compendium, Epitome of Medicine.

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Symeon Missios, Kimon Bekelis and Robert J. Spinner

Object

Despite the negative effects of peripheral nerve injuries (PNIs) on long-term population health, their true prevalence among pediatric trauma patients is under debate. The authors investigated the prevalence of PNIs among children involved in trauma and investigated associations between PNIs and several patient characteristics.

Methods

The authors performed a retrospective cohort study of pediatric trauma patients who were registered in the National Trauma Data Bank from 2009 through 2011 and who fulfilled the study inclusion criteria. They used regression techniques to investigate the association of demographic and socioeconomic factors with the rate of PNIs among these patients.

Results

Of the 245,470 study patients, 50,211 were involved in motor vehicle crashes, 3380 in motorcycle crashes, 20,491 in bicycle crashes, 18,262 in pedestrian accidents, 26,294 in other crashes (mainly involving all-terrain vehicles and snowmobiles), and 126,832 in falls. The respective prevalence of PNIs was 0.66% for motor vehicle crashes, 1% for motorcycle crashes, 0.38% for bicycle crashes, 0.42% for pedestrian accidents, 0.79% for other crashes, and 0.52% for falls. Multivariate logistic regression analysis demonstrated that the following were associated with an increased incidence of PNIs: increased patient age (OR 1.10, 95% CI 1.01–1.20), higher Injury Severity Score (OR 1.10, 95% CI 1.01–1.20), elevated systolic blood pressure at arrival at the emergency room (OR 1.10, 95% CI 1.01–1.20), and increased number of trauma surgeons at the institution (OR 1.10, 95% CI 1.01–1.20). The following were associated with lower incidence of PNIs: female sex (OR 0.94, 95% CI 0.87–1.02), rural hospitals (OR 0.94, 95% CI 0.87–1.02), and urban nonteaching hospitals (OR 0.94, 95% CI 0.87–1.02).

Conclusions

PNIs are more common than previously identified for the pediatric trauma population. These injuries are associated with older age and increased severity of the overall injury.

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Atman Desai, Kimon Bekelis, Wenyan Zhao and Perry A. Ball

Object

Motor vehicle accidents (MVAs) are a leading cause of death and disability in young people. Given that a major cause of death from MVAs is traumatic brain injury, and neurosurgeons hold special expertise in this area relative to other members of a trauma team, the authors hypothesized that neurosurgeon population density would be related to reduced mortality from MVAs across US counties.

Methods

The Area Resource File (2009–2010), a national health resource information database, was retrospectively analyzed. The primary outcome variable was the 3-year (2004–2006) average in MVA deaths per million population for each county. The primary independent variable was the density of neurosurgeons per million population in the year 2006. Multiple regression analysis was performed, adjusting for population density of general practitioners, urbanicity of the county, and socioeconomic status of the county.

Results

The median number of annual MVA deaths per million population, in the 3141 counties analyzed, was 226 (interquartile range [IQR] 151–323). The median number of neurosurgeons per million population was 0 (IQR 0–0), while the median number of general practitioners per million population was 274 (IQR 175–410). Using an unadjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.90 fewer MVA deaths per million population (p < 0.001). On multivariate adjusted analysis, each increase of 1 neurosurgeon per million population was associated with 1.01 fewer MVA deaths per million population (p < 0.001), with a respective decrease in MVA deaths of 0.03 per million population for an increase in 1 general practitioner (p = 0.007). Rural location, persistent poverty, and low educational level were all associated with significant increases in the rate of MVA deaths.

Conclusions

A higher population density of neurosurgeons is associated with a significant reduction in deaths from MVAs, a major cause of death nationally. This suggests that the availability of local neurosurgeons is an important factor in the overall likelihood of survival from an MVA, and therefore indicates the importance of promoting neurosurgical education and practice throughout the country.

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Atman Desai, Kimon Bekelis, Terrance M. Darcey and David W. Roberts

Intracranial electroencephalography monitoring of the insula is an important tool in the investigation of the insula in medically intractable epilepsy and has been shown to be safe and reliable. Several methods of placing electrodes for insular coverage have been reported and include open craniotomy as well as stereotactic orthogonal and stereotactic anterior and posterior oblique trajectories. The authors review each of these techniques with respect to current concepts in insular epilepsy.