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Myelomeningocele: surgical trends and predictors of outcome in the United States, 1988–2010

Clinical article

Varun R. Kshettry, Michael L. Kelly, Benjamin P. Rosenbaum, Andreea Seicean, Lee Hwang, and Robert J. Weil

Object

Myelomeningocele repair is an uncommonly performed surgical procedure. The volume of operations has been decreasing in the past 2 decades, probably as the result of public health initiatives for folate supplementation. Because of the rarity of myelomeningocele, data on patient or hospital factors that may be associated with outcome are scarce. To determine these factors, the authors investigated the trends in myelomeningocele surgical repair in the United States over a 23-year period and examined patient and hospital characteristics that were associated with outcome.

Methods

The Nationwide Inpatient Sample database for 1988–2010 was queried for hospital admissions for myelomeningocele repair. This database reports patient, hospital, and admission characteristics and surgical trends. The authors used univariate and multivariate logistic regression to assess associations between patient and hospital characteristics and in-hospital deaths, nonroutine discharge, long hospital stay, and shunt placement.

Results

There were 4034 hospitalizations for surgical repair of myelomeningocele. The annual volume decreased since 1988 but plateaued in the last 4 years of the study. The percentages of myelomeningocele patients with low income (30.8%) and Medicaid insurance (48.2%) were disproportionately lower than those for the overall live-born population (p < 0.0001). More operations per 10,000 live births were performed for Hispanic patients (3.2) than for white (2.0) or black (1.5) patients (p < 0.0001). Overall, 56.6% of patients required shunt placement during the same hospital stay as for surgical repair; 95.0% of patients were routinely discharged; and the in-hospital mortality rate was 1.4%. Nonwhite race was associated with increased in-hospital risk for death (OR 2.8, 95% CI 1.2–6.3) independent of socioeconomic or insurance status.

Conclusions

Overall, the annual surgical volume of myelomeningocele repairs decreased after public health initiatives were introduced but has more recently plateaued. The most disproportionately represented populations are Hispanic, low-income, and Medicaid patients. Among nonwhite patients, increased risk for in-hospital death may represent a disparity in care or a difference in disease severity.

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The shipboard Beirut terrorist bombing experience: a historical account and recommendations for preparedness in events of mass neurological injuries

Zachary S. Hubbard, Fraser Henderson Jr., Rocco A. Armonda, Alejandro M. Spiotta, Robert Rosenbaum, and Fraser Henderson Sr.

On a Sunday morning at 06:22 on October 23, 1983, in Beirut, Lebanon, a semitrailer filled with TNT sped through the guarded barrier into the ground floor of the Civilian Aviation Authority and exploded, killing and wounding US Marines from the 1st Battalion 8th Regiment (2nd Division), as well as the battalion surgeon and deployed corpsmen. The truck bomb explosion, estimated to be the equivalent of 21,000 lbs of TNT, and regarded as the largest nonnuclear explosion since World War II, caused what was then the most lethal single-day death toll for the US Marine Corps since the Battle of Iwo Jima in World War II. Considerable neurological injury resulted from the bombing. Of the 112 survivors, 37 had head injuries, 2 had spinal cord injuries, and 9 had peripheral nerve injuries. Concussion, scalp laceration, and skull fracture were the most common cranial injuries.

Within minutes of the explosion, the Commander Task Force 61/62 Mass Casualty Plan was implemented by personnel aboard the USS Iwo Jima. The wounded were triaged according to standard protocol at the time. Senator Humphreys, chairman of the Preparedness Committee and a corpsman in the Korean War, commented that he had never seen such a well-executed evolution. This was the result of meticulous preparation that included training not only of the medical personnel but also of volunteers from the ship’s company, frequent drilling with other shipboard units, coordination of resources throughout the ship, the presence of a meticulous senior enlisted man who carefully registered each of the wounded, the presence of trained security forces, and a drilled and functioning communication system.

Viewed through the lens of a neurosurgeon, the 1983 bombings and mass casualty event impart important lessons in preparedness. Medical personnel should be trained specifically to handle the kinds of injuries anticipated and should rehearse the mass casualty event on a regular basis using mock-up patients. Neurosurgery staff should participate in training and planning for events alongside other clinicians. Training of nurses, corpsmen, and also nonmedical personnel is essential. In a large-scale evolution, nonmedical personnel may monitor vital signs, work as scribes or stretcher bearers, and run messages. It is incumbent upon medical providers and neurosurgeons in particular to be aware of the potential for mass casualty events and to make necessary preparations.

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Dural arteriovenous fistulas masquerading as dural sinus thrombosis

Report of 2 cases

Scott Simon, Tom Yao, Arthur J. Ulm, Benjamin P. Rosenbaum, and Robert A. Mericle

The authors report dural sinus thrombosis diagnosed in 2 patients based on noninvasive imaging results, which were revealed to be dural arteriovenous fistulas (DAVFs) diagnosed using digital subtraction (DS) angiography. The first patient was a 63-year-old man who presented with headaches. Magnetic resonance venography was performed and suggested dural sinus thrombosis of the left transverse sinus and jugular vein. He was administered warfarin anticoagulation therapy but then suffered multiple intracranial hemorrhages. A DS angiogram was requested for a possible dural sinus thrombectomy, but the DS angiogram revealed a DAVF. The patient underwent serial liquid embolization with complete obliteration of the DAVF. The second patient, an 11-year-old boy, also presented with headaches and was diagnosed with dural sinus thrombosis on MR imaging. A DS angiogram was also requested for a possible thrombectomy and revealed a DAVF. This patient underwent serial liquid embolization and eventual operative resection. These reports emphasize that different venous flow abnormalities can appear similar on noninvasive imaging and that proper diagnosis is critical to avoid contraindicated therapies.

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Variations in cost calculations in spine surgery cost-effectiveness research

Matthew D. Alvin, Jacob A. Miller, Daniel Lubelski, Benjamin P. Rosenbaum, Kalil G. Abdullah, Robert G. Whitmore, Edward C. Benzel, and Thomas E. Mroz

Object

Cost-effectiveness research in spine surgery has been a prominent focus over the last decade. However, there has yet to be a standardized method developed for calculation of costs in such studies. This lack of a standardized costing methodology may lead to conflicting conclusions on the cost-effectiveness of an intervention for a specific diagnosis. The primary objective of this study was to systematically review all cost-effectiveness studies published on spine surgery and compare and contrast various costing methodologies used.

Methods

The authors performed a systematic review of the cost-effectiveness literature related to spine surgery. All cost-effectiveness analyses pertaining to spine surgery were identified using the cost-effectiveness analysis registry database of the Tufts Medical Center Institute for Clinical Research and Health Policy, and the MEDLINE database. Each article was reviewed to determine the study subject, methodology, and results. Data were collected from each study, including costs, interventions, cost calculation method, perspective of cost calculation, and definitions of direct and indirect costs if available.

Results

Thirty-seven cost-effectiveness studies on spine surgery were included in the present study. Twenty-seven (73%) of the studies involved the lumbar spine and the remaining 10 (27%) involved the cervical spine. Of the 37 studies, 13 (35%) used Medicare reimbursements, 12 (32%) used a case-costing database, 3 (8%) used cost-to-charge ratios (CCRs), 2 (5%) used a combination of Medicare reimbursements and CCRs, 3 (8%) used the United Kingdom National Health Service reimbursement system, 2 (5%) used a Dutch reimbursement system, 1 (3%) used the United Kingdom Department of Health data, and 1 (3%) used the Tricare Military Reimbursement system. Nineteen (51%) studies completed their cost analysis from the societal perspective, 11 (30%) from the hospital perspective, and 7 (19%) from the payer perspective. Of those studies with a societal perspective, 14 (38%) reported actual indirect costs.

Conclusions

Changes in cost have a direct impact on the value equation for concluding whether an intervention is cost-effective. It is essential to develop a standardized, accurate means of calculating costs. Comparability and transparency are essential, such that studies can be compared properly and policy makers can be appropriately informed when making decisions for our health care system based on the results of these studies.

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Oral Presentations 2015 AANS Annual Scientific Meeting Washington, DC • May 2–6, 2015

Published online August 1, 2015; DOI: 10.3171/2015.8.JNS.AANS2015abstracts

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Oral Presentations 2014 AANS Annual Scientific Meeting San Francisco, California • April 5–9, 2014

Published online June 1, 2015; DOI: 10.3171/2015.6.JNS.AANS2014abstracts