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Sebastian Salas-Vega, Vikram B. Chakravarthy, Robert D. Winkelman, Matthew M. Grabowski, Ghaith Habboub, Jason W. Savage, Michael P. Steinmetz, and Thomas E. Mroz

revision surgery and perioperative complications. 14 In the context of mounting economic pressures to limit the LOS, it is increasingly important to develop an improved understanding of the impact from clinical and nonclinical factors on LOS, patient outcomes, and costs associated with elective surgical procedures. In the present study, we used regularly collected hospital data to model the impact from clinical and nonclinical factors on patient LOS following elective lumbar laminectomy, a common surgical procedure that can be performed in both inpatient and

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Sunil Manjila, Tony Masri, Tanzila Shams, Shakeel A. Chowdhry, Cathy Sila, and Warren R. Selman

In this paper, the authors' aim is to provide an evidence-based review of primary and secondary ischemic stroke prevention guidelines covering most of the common risk factors and stroke etiologies for the practicing neurosurgeon. The key to stroke prevention is in the identification and treatment of the major risk factors for stroke. These include hypertension, heart disease, diabetes mellitus, dyslipidemia, and tobacco smoking. An updated approach to secondary prevention of stroke in the setting of intracranial and extracranial large vessel atherosclerosis and cardioembolism is provided along with a brief overview of pertinent clinical trials. Novel pharmacological options for prevention of cardioembolic strokes, such as new alternatives to warfarin, are addressed with recommendations for interruption of therapy for elective surgical procedures. In addition, the authors have reviewed the anticoagulation guidelines and the risk of thromboembolic complications of such therapies in the perioperative period, which is an invaluable piece of information for neurosurgeons. Less common etiologies such as arterial dissections and patent foramen ovale are also briefly discussed. Finally, the authors have outlined the quality measures in the Medicare Physician Quality Reporting System and essential guidelines for Primary Stroke Center certification, which have implications for day-to-day neurosurgical practice.

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Gail D. Anderson, Yi-Xin Lin, Carrie Berge, and George A. Ojemann

✓ Valproate (VPA) is associated with a variety of idiosyncratic hematological effects including thrombocytopenia, inhibition of platelet aggregation, and fibrinogen depletion. This has led some investigators to recommend discontinuation of VPA therapy prior to elective surgical procedures. However, administration of VPA therapy is not altered prior to surgery at the authors' center and no VPA-associated bleeding complications have been observed. Therefore, a retrospective chart review was conducted to verify the clinical observations in patients who had undergone cortical resection while receiving antiepileptic drugs (AEDs). Baseline, surgical, and postoperative laboratory data were available for a total of 313 patients, 111 of whom were receiving VPA and 202 of whom were receiving AEDs without VPA (control patients). Eighty-seven percent of the patients receiving VPA were also being treated with at least one other AED. The control group was approximately equally divided between monotherapy (55%) and polytherapy (45%) treatments. Platelet counts were significantly lower in the control polytherapy (284 ± 74 × 109/L) and both VPA groups (279 ± 113 × 109/L) as compared with the control monotherapy group (314 ± 85 × 109/L). Baseline fibrinogen levels were significantly lower in the VPA than in the control groups (223 ± 91 g/dl vs. 278 ± 95 g/dl). Both pre- and postoperatively, the VPA group had lower red blood cells counts, hematocrit, and hemoglobin levels. There was no significant difference between groups in estimated blood loss during surgery or qualitative wound discharge postsurgery. There was only one case of a bleeding complication, which occurred 14 days postoperatively in a patient receiving carbamazepine monotherapy. The results of this study confirm the clinical observations of an absence of bleeding complications in patients receiving VPA therapy at the time of surgery, despite differences in laboratory parameters.

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Victor E. Staartjes, Marlies P. de Wispelaere, and Marc L. Schröder

OBJECTIVE

Enhanced recovery after surgery (ERAS) has led to a paradigm shift in various surgical specialties. Its application can result in substantial benefits in perioperative healthcare utilization through preoperative physical and mental patient optimization and modulation of the recovery process. Still, ERAS remains relatively new to spine surgery. The authors report their 5-year experience, focusing on ERAS application to a broad population of patients with degenerative spine conditions undergoing elective surgical procedures, including anterior lumbar interbody fusion (ALIF).

METHODS

A multimodal ERAS protocol was applied between November 2013 and October 2018. The authors analyze hospital stay, perioperative outcomes, readmissions, and adverse events obtained from a prospective institutional registry. Elective tubular microdiscectomy and mini-open decompression as well as minimally invasive (MI) anterior or posterior fusion cases were included. Their institutional ERAS protocol contains 22 pre-, intra-, and postoperative elements, including preoperative patient counseling, MI techniques, early mobilization and oral intake, minimal postoperative restrictions, and regular audits.

RESULTS

A total of 2592 consecutive patients were included, with 199 (8%) undergoing fusion. The mean hospital stay was 1.1 ± 1.2 days, with 20 (0.8%) 30-day and 36 (1.4%) 60-day readmissions. Ninety-four percent of patients were discharged after a maximum 1-night hospital stay. Over the 5-year period, a clear trend toward a higher proportion of patients discharged home after a 1-night stay was observed (p < 0.001), with a concomitant decrease in adverse events in the overall cohort (p = 0.025) and without increase in readmissions. For fusion procedures, the rate of 1-night hospital stays increased from 26% to 85% (p < 0.001). Similarly, the average length of hospital stay decreased steadily from 2.4 ± 1.2 days to 1.5 ± 0.3 days (p < 0.001), with a notable concomitant decrease in variance, resulting in an estimated reduction in nursing costs of 46.8%.

CONCLUSIONS

Application of an ERAS protocol over 5 years to a diverse population of patients undergoing surgical procedures, including ALIF, for treatment of degenerative spine conditions was safe and effective, without increase in readmissions. The data from this large case series stress the importance of the multidisciplinary, iterative improvement process to overcome the learning curve associated with ERAS implementation, and the importance of a dedicated perioperative care team. Prospective trials are needed to evaluate spinal ERAS on a higher level of evidence.

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Wimar van den Brink

enroll him or her in a program, the third will actually perform the operation, and the fourth will do the follow-up. This is a large undertaking for the sake of efficiency. In these hectic settings, checks, double checks, and even triple and quadruple checks can be performed, but this method is only a quick fix for the potential dangers introduced by giving up the doctor-patient relationship. Irace and Corona only slightly mention this in their additional considerations: “… one of the crucial factors in successfully performing an elective surgical procedure is to

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Ági Oszvald, Hartmut Vatter, Christian Byhahn, Volker Seifert, and Erdem Güresir

surgical procedures, attention to quality and safety needs to be assured. To have a traceable and documented preoperative preparation of all patients undergoing any elective surgical procedure, we used a preoperative checklist in all elective surgical procedures starting in 2007. The publication of the Surgical Safety Checklist in January 2009 6 as well as the effect of the SURPASS (SURgical PAtient Safety System) on patient outcome in November 2010 4 led to reevaluation of our preoperative management. Therefore the checklist was extended in January 2011 according to

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Howard L. Weiner, P. David Adelson, Douglas L. Brockmeyer, Cormac O. Maher, Nalin Gupta, Matthew D. Smyth, Andrew Jea, Jeffrey P. Blount, Jay Riva-Cambrin, Sandi K. Lam, Edward S. Ahn, Gregory W. Albert, and Jeffrey R. Leonard

Journal of Neurosurgery: Pediatrics Editorial Board, the common concept being that decision-making remains dynamic and is modified as needed on a daily basis. Pediatric Neurosurgical Procedures Consistently at every center, nearly immediately, the decision to perform pediatric neurosurgical procedures followed the American College of Surgeons Clinical Issues and Guidance for the triage and management of elective surgical procedures ( https://www.facs.org/covid-19/clinical-guidance ), and the procedures were limited to only those defined as urgent. The rationale behind

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Handoyo Pramusinto, Daniel Agriva Tamba, Yoyok Subagio, Tommy J. Numberi, Bangun Pramujo, Franklin L. Sinanu, Gheanita Ariasthapuri, Haryo Bismantara, and Andreasta Meliala

adapted a recommendation from the ISNS to create hospital guidance for treating neurosurgical patients. Before each operative procedure, the patient was screened for COVID-19 using a SARS-CoV-2 antibody test kit. If the test was positive, they conducted a polymerase chain reaction (PCR) test. If a neurosurgical patient needed an elective surgical procedure but tested positive for COVID-19, the hospital would send the patient to a tertiary referral hospital for further management. Moderate-Risk COVID-19 Transmission Areas Sleman, Special Region of Yogyakarta On July 6

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Steven J. Schiff and Steven L. Weinstein

heterologous or autologous blood. 17 Clearly the use of recombinant erythropoietin may have a role in enabling patients to avoid blood transfusion during elective surgical procedures. This use would be predicated upon demonstrating that the risks of a 2- to 3-week course of erythropoietin would be lower than the risks of a 2-unit blood transfusion. As knowledge of blood-borne pathogens increases our concern regarding the risks of transfusion in all patients, the prospect of more widespread use of erythropoietin as a preoperative adjunct becomes more attractive

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Ankur Saxena and Sam Eljamel

and save is to use the gel column technique at an approximate cost of $24, which takes 30–45 minutes to complete. Cross-matching of serum would only take a few minutes following group and save. Therefore, if blood was required during surgery, cross-matching would only take approximately 60 minutes from requesting blood to delivery. The maximum surgical blood order schedule in the UK is a list of common elective surgical procedures performed with a maximum number of units of blood cross-matched preoperatively for each procedure. 4 , 9 Most UK hospitals have a