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BACKGROUND CONTEXT: The enhanced recovery after surgery (ERAS) protocol is a multimodal approach which has been shown to facilitate recovery of physiological function, and reduce early post-operative pain, complications, and length of stay (LOS) in open 1–2 level TLIF. The benefit of ERAS in specifically frail patients undergoing TLIF has not been demonstrated. Frailty is clinically defined as a syndrome of physiological decline that can predispose patients undergoing surgery to poor outcomes. PURPOSE: This study primarily evaluated the benefit of an ERAS protocol in frail patients undergoing 1- or 2-level open TLIF compared to frail patients without ERAS. Secondarily, we assessed whether outcomes in frail patients with ERAS approximated those seen in nonfrail patients with ERAS. STUDY DESIGN: Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLE: Consecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from August, 2015 to July, 2021 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURES: Primary outcome measure was return of postoperative physiological function defined as the summation of first day to ambulate, first day to bowel movement, and first day to void. Additional outcome measures included LOS, daily average pain scores, opioid use, discharge disposition, 30-day readmission rate, and reoperation. METHODS: A retrospective analysis of frail patients > 65 years of age undergoing 1–2 level open TLIF post-ERAS were compared to propensity matched frail pre-ERAS patients. Frailty was assessed using the Fried phenotype classification (score > 1). Patient demographics, LOS, first-day-to-ambulate (A1), first-day-to-bowel movement (B1), first-day-to-void (V1) were collected. Return of physiological function was defined as A1+B1+V1. Primary analysis was a comparison of frail patients pre-ERAS versus post-ERAS to determine effect of ERAS on return of physiologic function with frailty. Secondary analysis was a comparison of post-ERAS frail versus post-ERAS nonfrail patients to determine if return of physiologic function in frail patients with ERAS approximates that of nonfrail patients. RESULTS: In the primary analysis, 32 frail patients were included with mean age ± standard deviation of 72.8±4.4 years, mean BMI 28.8±5.5, 65.6% were male, 15 pre-ERAS and 17 post-ERAS. Patient characteristics were similar between groups. After ERAS implementation, return of physiological function improved by a mean 3.2 days overall (post-ERAS 3.4 vs. pre-ERAS 6.7 days) (p

OBJECTIVE The Enhanced Recovery After Surgery (ERAS) protocol is a comprehensive, multifaceted approach aimed at improving postoperative outcomes. It incorporates a range of strategies to promote early and more effective recovery, including reducing pain, complications, and length of stay, without increasing readmission rate. To date, ERAS for spine surgery patients has been primarily limited to lumbar surgery and anterior cervical decompression and fusion (ACDF). ERAS has not been previously studied for posterior cervical surgery, which may present a greater opportunity for improvement in patient outcomes with ERAS than ACDF. This single-institution, multi-surgeon study assessed the impact of an ERAS protocol in patients undergoing posterior cervical decompression surgery. METHODS This study included a retrospective consecutive patient cohort with controls that were propensity matched for age, body mass index, sex, home opioid use, surgical levels, Nurick grade, and smoking status. In addition, consecutive patients who underwent posterior cervical decompression surgery for degenerative disease from December 2014 to December 2021 were included. ERAS was implemented in December 2018. Demographic, perioperative, clinical, and radiographic information was gathered. Regression models were created to evaluate length of stay, physiological function, pain levels, and opioid use. The primary focus was length of stay, with secondary outcomes including timing of ambulation, bowel movement, and voiding; daily pain scores; opioid consumption; discharge status; 30-day readmission rates; and reoperation rates. RESULTS There were 366 patients included in the study, all of whom were included in multivariate models, and 254 (127 in each cohort) were included on the basis of matching. After propensity matching, patient characteristics, operative procedures, and operative duration were similar between groups. The ERAS cohort had a significantly improved length of stay (3.2 vs 4.7 days, p < 0.0001) and home discharge rate (80% vs 50%, p < 0.001) without an increase in readmission rate. The ERAS cohort had an earlier day of the first ambulation (p = 0.003), bowel movement (p = 0.014), and voiding (p = 0.001). ERAS demonstrated a significantly lower composite complication rate (1.1 vs 1.8, p < 0.0001). ERAS resulted in better maximum pain scores (p = 0.043) and trended toward improved mean pain scores (p = 0.072), although total opioid use was similar. CONCLUSIONS Implementing a novel ERAS protocol significantly improved length of stay, return of physiological function, home discharge, complications, and maximum pain score after posterior cervical surgery.

BACKGROUND: The enhanced recovery after surgery (ERAS) protocol is a multidisciplinary, multimodal approach which has been shown to facilitate recovery of physiological function, and reduce postoperative pain, complication rates, and length of stay without adversely affecting readmission rates. Design and implementation of ERAS protocols in the recent spine surgery literature has primarily focused on patients undergoing minimally invasive lumbar surgery. However, conventional open transforaminal lumbar interbody fusion (TLIF) remains a common procedure and to date there are no studies assessing an ERAS protocol in this patient population. PURPOSE: This study presents a single surgeon experience implementing an ERAS protocol in patients undergoing 1- or 2-level open TLIF. STUDY DESIGN/SETTING: Retrospective consecutive patient cohort with controls propensity-matched for age, body mass index, sex, and smoking status. PATIENT SAMPLE: Consecutive patients that underwent 1- or 2-level open TLIF for degenerative disease from 12/2018 – 02/2021 and controls from 12/2011–12/2017 by a single surgeon. ERAS was implemented in December 2018. OUTCOME MEASURES: Primary: length of stay; Secondary: first day to ambulate, first day to bowel movement, first day to void, daily average and maximum pain scores, opioid use, discharge disposition, 30-day readmission rate, and re-operations. METHODS: Demographic, perioperative, clinical, radiographic data were collected. Multivariate mixed-linear regression models were developed for length of stay, physiological function, pain scales, and opiate use. RESULTS: There were 114 patients included with 57 in each cohort. After propensity matching, patient characteristics were similar between groups. Operative time decreased significantly after institution of ERAS (170±44 vs. 141±37 minutes, p

Background and purpose Acute ischemic stroke has increasingly become a procedural disease following the demonstrated benefit of mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) on clinical outcomes and tissue salvage in randomized trials. Given these data and anecdotal experience of decreased numbers of decompressive hemicraniectomies (DHCs) performed for malignant cerebral edema, we sought to correlate the numbers of strokes, thrombectomies, and DHCs performed over the timeline of the 2013 failed thrombolysis/thrombectomy trials, to the 2015 modern randomized MT trials, to post-DAWN and DEFUSE 3. Materials and methods This is a multicenter retrospective compilation of patients who presented with ELVO in 11 US high-volume comprehensive stroke centers. Rates of tissue plasminogen activator (tPA), thrombectomy, and DHC were determined by current procedural terminology code, and specificity to acute ischemic stroke confirmed by each institution. Endpoints included the incidence of stroke, thrombectomy, and DHC and rates of change over time. Results Between 2013 and 2018, there were 55,247 stroke admissions across 11 participating centers. Of these, 6145 received tPA, 4122 underwent thrombectomy, and 662 patients underwent hemicraniectomy. The trajectories of procedure rates over time were modeled and there was a significant change in MT rate ( p = 0.002) without a concomitant change in the total number of stroke admissions, tPA administration rate, or rate of DHC. Conclusions This real-world study confirms an increase in thrombectomy performed for ELVO while demonstrating stable rates of stroke admission, tPA administration and DHC. Unlike prior studies, increasing thrombectomy rates were not associated with decreased utilization of hemicraniectomy.

OBJECTIVEThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) online surgical risk calculator uses inherent patient characteristics to provide predictive risk scores for adverse postoperative events. The purpose of this study was to determine if predicted perioperative risk scores correlate with actual hospital costs.METHODSA single-center retrospective review of 1005 neurosurgical patients treated between September 1, 2011, and December 31, 2014, was performed. Individual patient characteristics were entered into the NSQIP calculator. Predicted risk scores were compared with actual in-hospital costs obtained from a billing database. Correlational statistics were used to determine if patients with higher risk scores were associated with increased in-hospital costs.RESULTSThe Pearson correlation coefficient (R) was used to assess the correlation between 11 types of predicted complication risk scores and 5 types of encounter costs from 1005 health encounters involving neurosurgical procedures. Risk scores in categories such as any complication, serious complication, pneumonia, cardiac complication, surgical site infection, urinary tract infection, venous thromboembolism, renal failure, return to operating room, death, and discharge to nursing home or rehabilitation facility were obtained. Patients with higher predicted risk scores in all measures except surgical site infection were found to have a statistically significant association with increased actual in-hospital costs (p < 0.0005).CONCLUSIONSPrevious work has demonstrated that the ACS NSQIP surgical risk calculator can accurately predict mortality after neurosurgery but is poorly predictive of other potential adverse events and clinical outcomes. However, this study demonstrates that predicted high-risk patients identified by the ACS NSQIP surgical risk calculator have a statistically significant moderate correlation to increased actual in-hospital costs. The NSQIP calculator may not accurately predict the occurrence of surgical complications (as demonstrated previously), but future iterations of the ACS universal risk calculator may be effective in predicting actual in-hospital costs, which could be advantageous in the current value-based healthcare environment.

Objective Transforaminal lumbar interbody fusion (TLIF) is a common approach and results in varying degrees of lordosis correction. The purpose of this study is to determine preoperative radiographic spinopelvic parameters that predict change in postoperative segmental and lumbar lordosis after TLIF. Materials & Methods This study is a single surgeon retrospective review of one-level and two-level TLIFs from L3-S1. All patients underwent bilateral facetectomies, 10 mm TLIF cage (non-lordotic) insertions, and bilateral pedicle screw-rod construct placements. Pre- and post-operative X-rays were assessed for preoperative segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence (PI). Univariate and multi-predictor linear regression analyses were performed to determine the relationships between preoperative radiographic findings and change in early postoperative segmental and lumbar lordosis. Results Ninety-seven patients contributing 128 intervertebral segments were examined. The mean change in SL after TLIF was 7.3 (range: 0.10-28.9°, SD 6.39°). The mean change in LL after TLIF was 5.5˚ (range: -14.8-39.2°, standard deviation (SD) 7.16°). Greater preoperative LL predicted less postoperative LL correction, while greater preoperative PI predicted more postoperative SL and LL correction. Greater anterior disk height was noted to be associated with a decreased change in SL (∆SL). An annular tear on preoperative magnetic resonance imaging (MRI) predicted a 2.7° decrease in ∆SL. A Schmorl's node on preoperative MRI predicted a 4.0° decrease in change in LL (∆LL). Conclusions A greater preoperative lordosis and a lower spinopelvic mismatch lessen the potential for an increase in the postoperative SL and LL after a TLIF, which is likely due to a ‘ceiling’ effect of an otherwise optimized spinal alignment. A greater anterior disk height and the presence of an annular tear are associated with decreased ∆SL.

Background: Spontaneous intracerebral hemorrhage (ICH) is a significant cause of morbidity and mortality worldwide. The development of venous thromboembolism (VTE), including deep venous thrombosis or pulmonary embolism, is correlated with negative outcomes following ICH. Due to the risk of hematoma expansion associated with the use of VTE chemoprophylaxis, there remains significant debate about the optimal timing for its initiation following ICH. We analyzed the risk of early chemoprophylaxis on hematoma expansion following ICH. Methods: We performed a retrospective analysis of patients presenting with spontaneous ICH at single institution between 2011 and 2018. The rate of hematoma expansion was compared between patients that received early chemoprophylaxis (on admission) and those that received conventional chemoprophylaxis (>24 h). Results: Data for 235 patients were available for analysis. Eleven patients (7.5%) in the early prophylaxis cohort and seven patients (8.0%) in the conventional prophylaxis cohort developed VTE (P = 0.9). Hematoma expansion also did not differ significantly (early 19%, conventional 23%, P = 0.5). Conclusion: The use of early chemoprophylaxis against venous thromboembolic events following ICH appears safe in our patient population without increasing the risk of hematoma expansion. Given the increased risk of poor outcome in the setting of VTE, early VTE chemoprophylaxis should be considered in patients who present with ICH. Larger, prospective, and randomized studies are necessary to better elucidate the risk of early chemoprophylaxis and potential reduction in venous thromboembolic events.

Starting in the 1960s, ossification of the posterior longitudinal ligament (OPLL) became more commonly diagnosed in Japan. The disease is characterized by a gradual increase in calcification of the posterior longitudinal ligament with the eventual sequelae of cervical canal stenosis and myelopathy. Surgical interventions to relieve stenosis and neurologic symptoms are performed to decompress the cervical canal. Studies demonstrate continued ossification of the OPLL in both nonsurgical and surgically treated patients. In this review, the authors evaluate the epidemiology, pathophysiology, and literature regarding disease progression in OPLL after cervical fusion.

Primary Objective: The purpose of this study was to determine the utility of CT imaging in patients with non-operative mild-moderate TBI with respect to changes in management.Methods: We conducted a retrospective analysis for 191 patients over a 5-year interval to examine whether follow-up CT initiated a change in management. We created a logistic regression model to incorporate different variables contributing to change in management.Results: Of 191 patients, 31 (16.2%) underwent a change in management. Change in management was associated with older age (65 yo vs. 55 yo, p = .011), diagnosis of subdural hematoma (p = .041), antiplatelet/anticoagulant therapy (p = .009), imaging performed (p = .16), and increased blood products on CT (p =

Background and objectives Patient experience has become a quality measure in hospitals across the United States. To improve our understanding of our neurosurgical patient population's satisfaction needs, we undertook a detailed survey to identify areas of needed improvement. Methods Upon institutional review board approval, a detailed survey adopted from the Swedish quality-of-care patient questionnaire was distributed to all patients being discharged from the neurosurgical ward over a month period. From June 2014 to July 2014, all patients admitted to the neurosurgery service through the emergency department, clinic, or other facilities were enrolled. There were no specific inclusion criteria except for age older than 18 years, intact cognition to complete the survey, and return of a completed survey. Data were collected in 6 major categories, including information availability, patient accessibility, treatment received, caring perception, hospital environment, and overall satisfaction. Patients were evaluated by age, gender, surgery, and admission type. Results Our analysis demonstrated an improved overall satisfaction in those patients being admitted electively from the clinic as compared with emergency department admissions or hospital transfers. In addition, patients admitted on an emergent basis reported a lower satisfaction pertaining to receiving information, specifically test results. Conclusions Emergent admissions represent a subpopulation that may require additional strategies to improve patient satisfaction survey scores.

Objective. High frequency (HF) block can quickly and reversibly stop nerve conduction. We hypothesized HF block at the sciatic nerve would minimize nociception by preventing neuropathic signals from reaching the central nervous system. Approach. Lewis rats were implanted with a constriction cuff and a distal cuff electrode around their right sciatic nerve. Tactile sensitivity was evaluated using the 50% paw withdrawal threshold (PWT) determined using Chaplan’s method for von Frey monofilaments. Over the course of 49 d, the 50% PWT was measured (1) before HF block, (2) during HF block (50 kHz, 3 V pp), and (3) after HF block. Gait was observed and scored before and during block. At end point, HF block efficacy was directly evaluated using additional cuff electrodes to elicit and record compound neural action potentials across the HF blocking cuff. Main results. At days 7 and 14 d post-operation, tactile sensitivity was significantly lower during HF block compared to before and after block (p< 0.005). Additionally, an increase in gait disability was not visually observed during HF block. Significance. HF block can reduce tactile sensitivity in a limb with a neuropthic injury in a rapidly reversible fashion.

Background The benefits of telemedicine in neurosurgery have been widely studied, especially as its implementation into clinical practice boomed at the start of the COVID-19 pandemic. However, few studies have investigated telemedicine from the perspective of the patient experience. Objective To evaluate patient satisfaction scores of telemedicine outpatient clinic visits in neurosurgery in comparison with in-person visits. Methods After obtaining Institutional Review Board approval, Press Ganey surveys from 3/1/2019 to 9/15/2020 were evaluated retrospectively from single-institution, academic neurosurgical clinics. Due to the non-normality of our data, stratified Wilcoxon tests were performed with correction for care provider differences. Domain score probability values were corrected for multiple comparisons. Average scores (range 20–100) are documented as mean ± standard deviation. Results The response rates were 20% (97 responders) for telemedicine visits and 19% (589 responders) for in-person visits. Patient overall satisfaction score was slightly higher with telemedicine visits compared to in-person corrected for care provider differences (94.2 ± 12.2 vs 93.1 ± 13.4, p = 0.085). The care provider domain demonstrated no statistically significant difference in telemedicine compared to in-person (94.7 ± 14.4 vs 92.4 ± 16.5, p = 0.096). The access domain (93.7 ± 12.3 vs 93.4 ± 12.4, p = 0.999) and overall domains (94.1 ± 12.1 vs 94.4 ± 13.4, p = 1.000) were not found to be different between visit types. Conclusion Telemedicine appears to be a valuable option for neurosurgical patients and is not significantly different to in-person visits in all domains. This study demonstrates that telemedicine visits result in comparable satisfaction scores by neurosurgical patients, and providers should continue offering this option to their patients as we approach the post-COVID era.

Background Prophylactic use of antiepileptic drugs (AEDs) for patients undergoing brain tumor surgery is common practice despite lack of clear evidence. We hypothesized that prophylactic AED (pAED) use did not affect seizure rates in patients with brain tumor who underwent craniotomy for tumor resection. Methods A retrospective review was performed of 606 patients who underwent surgery for brain tumors from 2006 to 2013 at the University of Florida, excluding patients with preexisting seizure condition before tumor diagnosis. Data were analyzed to determine seizure incidence, AED use, and AED toxicities. Results Most patients (81%) had no seizure on presentation. Eight patients did not present with seizure but had seizure postoperatively, and 9 patients did not present with seizure or have seizure postoperatively but did have seizure on follow-up. Despite not presenting with a seizure preoperatively, 208 patients (43%) were placed on pAED preoperatively, 313 patients (64%) were on AED in the postoperative period, and 274 patients (56%) remained on AED at discharge. The pAED use odds ratio for seizures was 1.3 (95% confidence interval, 0.5–3.4; P = 0.599). At last follow-up, 34% of patients with no seizure on presentation remained on pAEDs. Conclusions pAEDs did not significantly reduce postoperative seizures in patients with brain tumor in this analysis. In addition, pAED was often continued once prescribed even if the patient remained seizure free.

Introduction The most common bone flap storage strategies after decompressive hemicraniectomy for malignant intracranial hypertension include freezer cryopreservation (CP) and subcutaneous abdominal implantation (AP). Numerous series have reported on patient outcomes after cranioplasty in terms of infection, cosmesis, and resorption. This meta-analysis compares published outcomes of bone flap CP and subcutaneous storage with respect to efficacy and complication risk in patients undergoing cranioplasty after hemicraniectomy. Methods A systematic review was performed using PubMed-searchable studies that included bone flap storage methods and outcome data for cranioplasties performed between 1975 and 2015. Results A total of 48 studies including 5346 patients were identified that met the inclusion criteria. Of these patients, 4096 underwent cranioplasty with an autologous flap. Mean bone flap storage times for CP and AP flaps were 69.9 and 69.7 days. Mean follow-up time for CP and AP flaps was 16.9 and 16.5 months. No statistically significant differences were found when comparing CP with subcutaneous storage of bone flaps with respect to percentage of patients developing infection (7.3% vs. 7.1%), percentage of patients needing revision surgery (15.9% vs. 7.6%), and percentage of patients experiencing resorption (9.7% vs. 7.7%). Conclusions This is the largest and most robust review comparing published outcomes of CP and subcutaneous storage of bone flaps in patients who have undergone decompressive hemicraniectomy. This review found no statistically significant differences in clinical outcomes (infection, resorption, reoperation) when comparing storage methods for bone flap preservation. This study suggests that both strategies may be used safely and successfully.

The frontal lobe urinary control center is an important regulator of urinary function. Neurologic injury often causes damage or temporary dysfunction of this center and other related urinary control pathways. Little has been reported about this topic in the literature although a majority of neurologic injury patients suffer from some type of urinary dysfunction. In this review, we highlight what is known about urinary dysfunction based on injury type (traumatic brain injury, hemorrhagic stroke, ischemic stroke, subarachnoid hemorrhage, subdural hematoma, and epilepsy). We discuss both clinical and pre-clinical data and pinpoint areas warranting further investigation. In the final section, we provide proposed practice suggestions for managing these patients clinically with the intended goal for refinement in these approaches following further clinical trials.

We describe the case of a 52-year-old woman with scleritis caused by an imipenem-resistant strain of Nocardia beijingensis. The patient presented with pain, redness, and nodules on the sclera of 8 weeks’ duration. A Gram stain from a nodule on the superonasal aspect of the globe was initially negative. After empiric treatment for an autoimmune etiology, cytopathology confirmed filamentous bacteria. A presumptive diagnosis of Nocardia scleritis was made, and medical management was based on a literature review on treatments for Nocardia infections. Cultures returned confirming Nocardia beijingensis. Antibiotic sensitivity testing confirmed the correct initial management. The patient’s scleritis resolved with a good visual outcome.

STUDY DESIGN A retrospective national administrative database study. OBJECTIVE Advances in treatment of traumatic cervical spinal cord injury with fracture (TCSCIF) have led to significant improvements in clinical outcomes; however, progress in healthcare is seldom ubiquitous across demographic groups. Therefore, we explored if disparities in treatment and outcome after TCSCIF exist across race and socioeconomic status. SETTING USA. METHODS We queried the Nationwide Inpatient Sample database from 1998 to 2009 for TCSCIF hospitalizations. Multivariate analysis was used to identify the correlation between socioeconomic status and race to injury, treatment type, and outcome. RESULTS There were 21,985 admissions for TCSCIF, 66.9% of whom had a favorable discharge disposition. In-hospital mortality rate was 12.5%. A total of 43.7% underwent surgery. Overall, surgery was associated with lower in-hospital mortality (OR 0.30, 95% CI 0.27-0.34, p

While the incidence of postoperative infection after spine surgery is relatively uncommon, the occurrence of a surgical site infection can significantly impact individual patient outcome. Spinal deformity surgery carries a higher risk of infection compared to other spinal procedures. Posterior approach, increased number of treated levels and length of surgery, use of spinal instrumentation and grafts, and revision surgery likely contribute to greater risk of infection. Clinical presentation (symptoms, physical exam findings, diagnostic studies) and management options are reviewed in a case-based format.

We describe the case of a 52-year-old woman with scleritis caused by an imipenem-resistant strain of Nocardia beijingensis. The patient presented with pain, redness, and nodules on the sclera of 8 weeks’ duration. A Gram stain from a nodule on the superonasal aspect of the globe was initially negative. After empiric treatment for an autoimmune etiology, cytopathology confirmed filamentous bacteria. A presumptive diagnosis of Nocardia scleritis was made, and medical management was based on a literature review on treatments for Nocardia infections. Cultures returned confirming Nocardia beijingensis. Antibiotic sensitivity testing confirmed the correct initial management. The patient’s scleritis resolved with a good visual outcome.

OBJECTIVEThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) universal Surgical Risk Calculator is an online decision-support tool that uses patient characteristics to estimate the risk of adverse postoperative events. Further validation of this risk calculator in the neurosurgical population is needed; therefore, the object of this study was to assess the predictive performance of the ACS NSQIP Surgical Risk Calculator in neurosurgical patients treated at a tertiary care center.METHODSA single-center retrospective review of 1006 neurosurgical patients treated in the period from September 2011 through December 2014 was performed. Individual patient characteristics were entered into the NSQIP calculator. Predicted complications were compared with actual occurrences identified through chart review and administrative quality coding data. Statistical models were used to assess the predictive performance of risk scores. Traditionally, an ideal risk prediction model demonstrates good calibration and strong discrimination when comparing predicted and observed events.RESULTSThe ACS NSQIP risk calculator demonstrated good calibration between predicted and observed risks of death (p = 0.102), surgical site infection (SSI; p = 0.099), and venous thromboembolism (VTE; p = 0.164) Alternatively, the risk calculator demonstrated a statistically significant lack of calibration between predicted and observed risk of pneumonia (p = 0.044), urinary tract infection (UTI; p < 0.001), return to the operating room (p < 0.001), and discharge to a rehabilitation or nursing facility (p < 0.001). The discriminative performance of the risk calculator was assessed using the c-statistic. Death (c-statistic 0.93), UTI (0.846), and pneumonia (0.862) demonstrated strong discriminative performance. Discharge to a rehabilitation facility or nursing home (c-statistic 0.794) and VTE (0.767) showed adequate discrimination. Return to the operating room (c-statistic 0.452) and SSI (0.556) demonstrated poor discriminative performance. The risk prediction model was both well calibrated and discriminative only for 30-day mortality.CONCLUSIONSThis study illustrates the importance of validating universal risk calculators in specialty-specific surgical populations. The ACS NSQIP Surgical Risk Calculator could be used as a decision-support tool for neurosurgical informed consent with respect to predicted mortality but was poorly predictive of other potential adverse events and clinical outcomes.

The most widely used intracranial stents for stent-assisted coiling are Neuroform (NEU) and Enterprise stents (ENT). This study compares published outcomes between the ENT and NEU coil-assist systems and comments on the published safety and efficacy of stent-assisted coiling in general.A literature search was performed through PubMed for all published series of ENT or NEU stent-assisted coiling of cerebral aneurysms from 2004 to 2014. All studies including 10 or more published cases of stent-assisted coiling with ENT or NEU were included.47 studies met the inclusion criteria, containing 4238 aneurysms in 4039 patients. 2111 aneurysms were treated with NEU and 2127 were treated with ENT. Mean follow-up was 14.1 months. Overall, thromboembolic events occurred in 6.4% of aneurysms, intracranial hemorrhage (ICH) in 2.6%, permanent morbidity in 3.9%, and mortality in 2.3%. Initial and final 100% angiographic occlusion was seen in 53% and 69% of patients, respectively. Deployment failures (p0.001), ICH (p=0.001), mortality among all patients (p=0.03), and recanalization (p=0.02) were more commonly reported in NEU treated aneurysms. The ENT system was also associated with higher reported complete occlusion at follow-up (p0.001).This literature review represents the largest and most robust comparison of stent-assisted coiling devices to date, containing over 4200 aneurysms in more than 4000 patients. Comparative analyses demonstrate that both devices are reported to be safe and effective with comparable permanent morbidity.

Objective To identify deficiencies leading to readmissions to the University of Florida Neurosurgery Service by using the Institute for Healthcare Improvement STate Action on Avoidable Rehospitalizations Readmissions diagnostic tool and to report the opinions of patients, their families, and health care providers. Methods A retrospective review of hospital admission and discharge data was conducted. All patients who met eligibility criteria and who were discharged from the neurosurgery service between January 1 and March 31, 2012, and readmitted within 30 days after discharge ( n = 74; 66 patients; 7 multiple readmissions) were included. A chart review revealed potential precipitating factors. Health care providers, patients, and family members were also interviewed. Median values and frequencies were used to summarize the data. Results The 30-day readmission rate on the neurosurgery service was 14%. Problems associated with wound care accounted for 24% of readmissions, neurologic conditions accounted for 50%, and other medical conditions accounted for 26%. Patients and providers agreed on the medical diagnoses resulting in readmission, but providers also often named "patient noncompliance" as a factor leading to readmission, whereas patients often thought they either were "sent home too early" or had a "general decline with no improvement." Conclusions Systematic patterns and common themes associated with patient readmissions were identified for a neurosurgical service. These findings are now being used to implement changes in discharge planning.

Objective In response to rising national health expenditures, the Patient Protection and Affordable Care Act (ACA) was passed in 2010, with major provisions implemented in 2014. Due to increasing concerns about workload and compensation among neurosurgeons, we evaluated trends in neurosurgical reimbursement, productivity and compensation before and after the implementation of the major provisions of the ACA. Patients and Methods Results from Neurosurgery Executives’ Resource Value and Education Society (NERVES) annual surveys were collected, representing data from 2011 to 2016. Responses from different practice settings across the six years were categorized into groups, and inverse variance-weighted averaging was performed within the frameworks of a one-way ANOVA model with year. Data from 2011 to 2013 and 2014–2016 were analyzed similarly for differences among practice setting and region. Results The NERVES survey response rates ranged from 20% to 36%. Median values for compensation decreased by 3.66%, 6.42%, and 10.34% within private, hospital, and academic practices respectively after 2014 although these trends did not reach statistical significance. Median work RVUs had a trend to decrease by 5.67%, 13.08%, and 19.44% within private, hospital, and academic practices respectively after 2014. Academic practices showed statistically significant decreases in annual total RVUs, total gross charges and collections. Conclusion These data demonstrate neurosurgical reimbursement and productivity have trended down during a time that increases in productivity and reimbursement were predicted. This phenomenon is most notable in academic practices compared to private or hospital based practices. Prospective analyses of the impact of healthcare policy reform on neurosurgical productivity are urgently needed.

OBJECTIVEAn increased extent of resection (EOR) has been shown to improve overall survival of patients with glioblastoma (GBM) but has the potential for causing a new postoperative neurological deficit. To investigate the impact of surgical neurological morbidity on survival, the authors performed a retrospective analysis of the clinical data from patients with GBM to quantify the impact of a new neurological deficit on the survival benefit achieved with an increased EOR.METHODSThe data from all GBM patients who underwent resection at the University of Florida from 2010 to 2015 with postoperative imaging within 72 hours of surgery were included in the study. Retrospective analysis was performed on clinical outcomes and tumor volumes determined on postoperative and follow-up imaging examinations.RESULTSOverall, 115 patients met the inclusion criteria for the study. Tumor volume at the time of presentation was a median of 59 cm3 (enhanced on T1-weighted MRI scans). The mean EOR (± SD) was 94.2% ± 8.7% (range 59.9%–100%). Almost 30% of patients had a new postoperative neurological deficit, including motor weakness, sensory deficits, language difficulty, visual deficits, confusion, and ataxia. The neurological deficits had resolved in 41% of these patients on subsequent follow-up examinations. The median overall survival was 13.1 months (95% CI 10.9–15.2 months). Using a multipredictor Cox model, the authors observed that increased EOR was associated with improved survival except for patients with smaller tumor volumes (≤ 15 cm3). A residual volume of 2.5 cm3 or less predicted a favorable overall survival. Developing a postoperative neurological deficit significantly affected survival (9.2 months compared with 14.7 months, p = 0.02), even if the neurological deficit had resolved by the first follow-up. However, there was a trend of improved survival among patients with resolution of a neurological deficit by the first follow-up compared with patients with a permanent neurological deficit. Any survival benefit from achieving a 95% EOR was abrogated by the development of a new neurological deficit postoperatively.CONCLUSIONSDeveloping a new neurological deficit after resection of GBM is associated with a decrease in overall survival. A careful balance between EOR and neurological compromise needs to be taken into account to reduce the likelihood of neurological morbidity from surgery.

Though no clear evidence supports seizure prophylaxis in patients with cerebral tumors, prophylactic use of anti-epileptic drugs (AEDs) for patients undergoing tumor surgery is common practice. A retrospective chart review was performed of 609 consecutive patients from 2010-2013 who underwent surgery for brain neoplasms at the University of Florida. Patients who did not present with seizures preoperatively were divided into supratentorial and infratentorial groups. There were 357 patients with supratentorial tumors with 297 (83.2%) receiving AEDs post-operatively and 60 (16.8%) not receiving AEDs. From surgery to last follow-up, one patient (2%) in the non-AED group had a seizure and 15 (6.2%) in the AED group had seizures (p = 0.487). There were 129 patients with infratentorial tumors, with 32 (24.8%) receiving AEDs and 97 (75.2%) not receiving AEDs. In the post-operative period, one patient (1.2%) in the non-AED group had a seizure and zero in the AED group had a seizure (p = 1). 16 (5.4%) patients in the supratentorial group and 3 (9.4%) patients in the infratentorial group on AEDs experienced toxicity related to AEDs. At discharge, 254 patients (85.5%) with supratentorial tumors without seizures remained on AEDs. At last follow up, 129 patients (53.8%) with supratentorial tumors remained on AEDs despite no seizures. AEDs do not significantly reduce post-operative seizures in surgical brain tumor patients in this analysis. Additionally, once a patient is prescribed an AED, discontinuation of AED therapy is unlikely, even if the patient remains seizure free.

Repetitive behaviors are diagnostic for autism and common in related neurodevelopmental disorders. Despite their clinical importance, underlying mechanisms associated with the expression of these behaviors remain poorly understood. Our lab has previously shown that the rates of spontaneous stereotypy in deer mice (Peromyscus maniculatus) were negatively correlated with enkephalin content, a marker of striatopallidal but not striatonigral neurons. To investigate further the role of the indirect basal ganglia pathway, we examined neuronal activation of the subthalamic nucleus (STN) using cytochrome oxidase (CO) histochemistry in high- and low-stereotypy mice. CO activity in STN was significantly lower in high-stereotypy mice and negatively correlated with the frequency of stereotypy. In addition, exposure to environmental enrichment, which attenuated stereotypy, normalized the activity of STN. Co-administration of the adenosine A(2A) receptor agonist CGS21680 and the A(1) receptor agonist CPA attenuated stereotypy dose-dependently. The significant reduction associated with the lowest dose of the drug combination tested was due to its effects on mice with lower baseline levels of stereotypy. Higher doses of the drug combination were required to show robust behavioral effects, and presumably requisite activation of the indirect pathway, in high-stereotypy mice. These findings support that decreased indirect pathway activity is linked to the expression of high levels of stereotypy in deer mice and that striatal A(1) and A(2A) receptors may provide promising therapeutic targets for the treatment of repetitive behaviors in neurodevelopmental disorders.