Full-Extension Eyebrow Approach with Supraorbital Nerve Preservation for Frontal Sinus Tumors.

Frontal sinus surgery still represents a challenge due to its complex and highly variable anatomy. In this manuscript, we present a detailed anatomical description of an eyebrow approach that allows full exposure of the frontal sinus with a large osteoplastic bone flap and preservation of the supraorbital nerve. Laryngoscope, 134:1633-1637, 2024.

The Lingual Process of the Sphenoid Bone and the Petrolingual Ligament: Surgical Anatomy, Landmarks, and Clinical Relevance.

BACKGROUND: The lingual process of the sphenoid bone (LP) and the petrolingual ligament (PLL) surround laterally the internal carotid artery within the middle cranial fossa (MCF). OBJECTIVE: To study the LP and the PLL and anatomical variations considering their relationships with different structures and landmarks within the MCF, especially oriented toward the endoscopic endonasal approaches. METHODS: Seventy-two sides of dry skulls and 20 sides of embalmed specimens were studied. The measurements of the LP and the PLL were obtained, considering important landmarks in the MCF. RESULTS: The LP had a mean length and height of 5 mm and 3 mm, respectively. Its distance from the foramen lacerum was 6 mm, from the foramen ovale 10 mm, foramen rotundum 15 mm, and petrous apex 9 mm. In 44 sides (61.11%), the LP partially closed the lateral aspect of the carotid sulcus; in 17 sides (23.61%), it was found as a near-ring; and in 11 sides (15.2%), it was considered rudimentary. Considering the PLL, its length and height were, respectively, 9 mm, and 4 mm. CONCLUSION: The LP and PLL separate the carotid artery at the inferior aspect of Meckel's cave and constitute important landmarks for endoscopic endonasal approaches to Meckel's cave and MCF, and their identification and removal is essential for internal carotid artery mobilization in this area.

Quantitative Anatomic Comparison of Endoscopic Transnasal and Microsurgical Transcranial Approaches to the Anterior Cranial Fossa.

BACKGROUND: Several microsurgical transcranial approaches (MTAs) and endoscopic transnasal approaches (EEAs) to the anterior cranial fossa (ACF) have been described. OBJECTIVE: To provide a preclinical, quantitative, anatomic, comparative analysis of surgical approaches to the ACF. METHODS: Five alcohol-fixed specimens underwent high-resolution computed tomography. The following approaches were performed on each specimen: EEAs (transcribriform, transtuberculum, and transplanum), anterior MTAs (transfrontal sinus interhemispheric, frontobasal interhemispheric, and subfrontal with unilateral and bilateral frontal craniotomy), and anterolateral MTAs (supraorbital, minipterional, pterional, and frontotemporal orbitozygomatic approach). An optic neuronavigation system and dedicated software (ApproachViewer, part of GTx-Eyes II-UHN) were used to quantify the working volume of each approach and extrapolate the exposure of different ACF regions. Mixed linear models with random intercepts were used for statistical analyses. RESULTS: EEAs offer a large and direct route to the midline region of ACF, whose most anterior structures (ie, crista galli, cribriform plate, and ethmoidal roof) are also well exposed by anterior MTAs, whereas deeper ones (ie, planum sphenoidale and tuberculum sellae) are also well exposed by anterolateral MTAs. The orbital roof region is exposed by both anterolateral and lateral MTAs. The posterolateral region (ie, sphenoid wing and optic canal) is well exposed by anterolateral MTAs. CONCLUSION: Anterior and anterolateral MTAs play a pivotal role in the exposure of most anterior and posterolateral ACF regions, respectively, whereas midline regions are well exposed by EEAs. Furthermore, certain anterolateral approaches may be most useful when involvement of the optic canal and nerves involvement are suspected.

Trends in Admissions and Outcomes for Treatment of Aneurysmal Subarachnoid Hemorrhage in the United States.

BACKGROUND: Lifestyle modifications and advances in surgical and endovascular techniques for treating unruptured intracranial aneurysm (UIA) have vastly evolved over the last few decades and may have reduced the incidence of aneurysmal subarachnoid hemorrhage (aSAH). However, the actual impact of these changes on the rates and outcomes of aSAH remain unexplored. Thus, we studied national aSAH admissions and outcome trends and changes of major risk factors over time. METHODS: We queried the National Inpatient Sample between 2006 and 2018 to identify adult patients admitted and treated for UIA or ruptured aneurysm with aSAH. The Cochran-Armitage test was conducted to assess the linear trend of proportion of prevalence, inpatient mortality, hypertension, and current smoking status among aSAH admissions. Multivariable logistic regression was conducted to assess the odds of presenting with aSAH versus UIA, in addition to the odds of inpatient mortality among patients with aSAH. RESULTS: A total of 159,913 patients presented with UIA and 133,567 presented with aSAH. Admissions for aSAH decreased by 0.97% (p < 0.001) per year. Current smoking and hypertension were associated with higher odds of being admitted for aSAH compared with the treatment for UIA (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.29-1.48; OR 1.15, 95% CI 1.08-1.22, respectively). Compared with White patients, Black patients (OR 1.32, 95% CI 1.21-1.43), Hispanic patients (OR 1.38, 95% CI 1.25-1.52), and patients of other races and/or ethnicities (OR 1.73, 95% CI 1.54-1.95) had a higher chance of presenting with aSAH. Rates of inpatient mortality among aSAH admissions showed no change over time (p = 0.21). Among patients admitted with aSAH, current smoking and hypertension showed an upward trend of 0.58% (p < 0.001) and 1.60% (p < 0.001) per year, respectively. CONCLUSIONS: Despite a downward trend in the annual frequency of hospitalizations for aSAH, inpatient mortality rates for patients undergoing treatment of the ruptured aneurysm have remained unchanged in the United States. Smoking and hypertension are increasingly prevalent among patients with aSAH. Thus, efforts to control these modifiable risk factors must be further strengthened.

Trends in Utilization of Preoperative Embolization for Spinal Metastases: A Study of the National Inpatient Sample 2005-2017.

PURPOSE: While previous studies have suggested that preoperative embolization of hypervascular spinal metastases may alleviate intraoperative blood loss and improve resectability, trends and driving factors for choosing this approach have not been extensively explored. Therefore, we evaluated the trends and assessed the factors associated with preoperative embolization utilization for spinal metastatic tumors using a national inpatient database. MATERIALS AND METHODS: The National Inpatient Sample database of the Healthcare Cost and Utilization Project was queried for patients undergoing surgical resection for spinal metastasis between January 1, 2005 and December 31, 2017. Patients undergoing preoperative embolization were identified; trends in the utilization of preoperative embolization were analyzed using the Cochran-Armitage test. Multivariable regression was conducted to assess factors associated with higher preoperative embolization utilization. RESULTS: A total of 11,508 patients with spinal metastasis were identified; 105 (0.91%) underwent preoperative embolization. Of those 105 patients, 79 (75.24%) patients had a primary renal cancer, as compared to 1,732 (15.19%) of those who did not undergo preoperative embolization (P<0.001). The majority of patients in the non-preoperative embolization cohort had a primary lung tumor (n=3,562, 31.24%). Additionally, patient comorbidities were similar among the 2 groups (P>0.05). Trends in preoperative embolization indicated an increase of 0.16% (standard error: 0.024%, P<0.001) in utilization per year. CONCLUSION: Utilization of preoperative embolization for spinal metastasis is increasing yearly, especially for patients with renal cancer, suggesting that surgeons may increasingly consider embolization before surgical resection for hypervascular tumors. Additionally, the literature has shown the intraoperative and postoperative benefits of this procedure.

Is the current insurance structure leading to seasonality in demand for spinal surgery? A quarterly, yearly, and insurance based analysis.

BACKGROUND: Elective lumbar fusion is a commonly employed procedure for degenerative lumbar spine disease. With healthcare costs rising reimbursement for procedures may be restricted by payers. Additionally, patients may undergo elective fusion once deductibles are covered, typically in the fourth quarter in a given year. The objective of this study was to analyze the trends in utilization for posterior lumbar fusion (PLF) earlier in the year (Q1-Q3) as compared to the end of the year(Q4). Variations in this proposed trend by insurance type were also studied as a primary outcome. METHODS: We queried the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) between January 1, 2012 and December 31, 2014 for patients diagnosed with lumbar disc degenerative disease (DDD). Outcomes of interest included utilization and frequency of PLF. RESULTS: 221,466 patients hospitalized with Lumbar DDD between 2012 and 2014 were identified. Of these, 67,343(30.4 %) underwent a PLF procedure. The likelihood of lumbar fusion in patients hospitalized with DDD was significantly higher in the 4th quarter, compared to 1st quarter (OR1.13, p < 0.001). Marginal effect analysis indicated that Medicare patients were 1.0 % more likely to undergo PLF in quarter 4 compared to quarters 1-3 (p = 0.003), while privately insured patients were 2.5 % more likely to undergo PLF in quarter 4 compared to quarters 1-3(p < 0.001). CONCLUSION: These results indicate that utilization of PLF is higher at the end of the year relative to the beginning, especially for patients with private insurance. This may be due to deductibles that have previously been paid off, lowering out-of-pocket expenses.

Minimally Invasive Versus Open Surgery for Degenerative Spine Disorders for Elderly Patients: Experiences from a Single Institution.

BACKGROUND: Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients. METHODS: Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications. RESULTS: A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P < 0.001), operative time (P < 0.001), and LOS (P < 0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance. CONCLUSIONS: These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.

A Case Management System for Integrating Patient-reported Outcome Assessment in Clinical Practice: The Beacon Tool.

INTRODUCTION: What if you could only ask one question of the patient during a clinic visit? Further, suppose the patient's biggest concern can pragmatically be incorporated into routine clinical care and clinical pathways that can address the patient's single biggest concern can be identified. If the principal concern can be dealt with efficiently at each visit through key stakeholder case management, positive outcomes should result. Therefore, motivated by the need for patient-centered health care visits, the Beacon electronic patient-reported outcomes (PRO) quality of life (QOL) tool was developed. METHODS: Central to the tool is that at each health care visit, the patient's biggest concern is electronically communicated to the health care team. Therefore, the tool can help catalyze important discussions between the health care team and the patient, perhaps on topics that would not have been discussed otherwise at a routine visit. In recognition of the community of resources needed to provide comprehensive care, the tool generates clinical pathways or actions that can be pursued to address the patient's biggest concern. The concern is efficiently triaged such that members of the health care community with appropriate expertise and resources are identified to address and manage that single biggest concern signaled by the patient. A report, which can be uploaded into the patient's medical chart, is created and provides a list of resources for a case manager to assist the patient and contains graphical presentations of the patient's QOL and a history of prior concerns. The report also labels potentially significant changes in QOL. DISCUSSION: The tool, which has been applied successfully in several health conditions, acts as a beacon to health care providers so that a patient's self-reported concern can be consistently and effectively integrated into their care. KEY POINTS: It is impractical to try to deal with every patient concern in every visit. The key to the Beacon tool is that at each visit the patient's biggest concern is identified, clinical pathways indicated, and resources efficiently matched to address the patient's biggest concern.

Developing a toolkit to implement the Statin Choice Conversation Aid at scale: application of a work reduction model.

BACKGROUND: Guidelines recommend shared decision making (SDM) for determining whether to use statins to prevent cardiovascular events in at-risk patients. We sought to develop a toolkit to facilitate the cross-organizational spread and scale of a SDM intervention called the Statin Choice Conversation Aid (SCCA) by (i) assessing the work stakeholders must do to implement the tool; and (ii) orienting the resulting toolkit's components to communicate and mitigate this work. METHODS: We conducted multi-level and mixed methods (survey, interview, observation, focus group) characterizations of the contexts of 3 health systems (n = 86, 84, and 26 primary care clinicians) as they pertained to the impending implementation of the SCCA. We merged the data within implementation outcome domains of feasibility, appropriateness, and acceptability. Using Normalization Process Theory, we then characterized and categorized the work stakeholders did to implement the tool. We used clinician surveys and IP address-based tracking to calculate SCCA usage over time and judged how stakeholder effort was allocated to influence outcomes at 6 and 18 months. After assessing the types and impact of the work, we developed a multi-component toolkit. RESULTS: At baseline, the three contexts differed regarding feasibility, acceptability, and appropriateness of implementation. The work of adopting the tool was allocated across many strategies in complex and interdependent ways to optimize these domains. The two systems that allocated the work strategically had higher uptake (5.2 and 2.9 vs. 1.1 uses per clinician per month at 6 months; 3.8 and 2.1 vs. 0.4 at 18 months, respectively) than the system that did not. The resulting toolkit included context self-assessments intended to guide stakeholders in considering the early work of SCCA implementation; and webinars, EMR integration guides, video demonstrations, and an implementation team manual aimed at supporting this work. CONCLUSIONS: We developed a multi-component toolkit for facilitating the scale-up and spread of a tool to promote SDM across clinical settings. The theory-based approach we employed aimed to distinguish systems primed for adoption and support the work they must do to achieve implementation. Our approach may have value in orienting the development of multi-component toolkits and other strategies aimed at facilitating the efficient scale up of interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02375815 .

The Southeastern Minnesota Beacon Project for Community-driven Health Information Technology: Origins, Achievements, and Legacy.

INTRODUCTION: The Southeastern (SE) Minnesota Beacon organized all the health care providers, county public health organizations, and school districts in the deployment and integration of health information exchange (HIE) and targeted health communication around childhood asthma and diabetes. The community cooperated to establish a clinical data repository for all residents in the 11-county region. Through this community of practice approach that involved traditional and nontraditional providers, the SE Minnesota Beacon was able to realize unique applications of this technology. This manuscript overviews the associated organization and infrastructure of this community collaboration. BACKGROUND: The Office of the National Coordinator for Health Information Technology (ONC), as part of the American Recovery and Reinvestment Act of 2009 (ARRA) stimulus, established 17 projects throughout the United States targeting the introduction and meaningful use of health information technology (HIT). These 17 communities were intended to serve as an example of what could be accomplished. The SE Minnesota Beacon is one of these communities. METHODS: The community ultimately opted for peer-to-peer HIE, using Nationwide Health Information Network (NwHIN) Connect software. The clinical data repository was established using the infrastructure developed by the Regenstrief Institute, which operated as a trusted third party. As an extension to HIE, the consortium of county public health departments created a patient data portal for use by school nurses and parents. Childhood asthma was addressed by creating, exchanging, and maintaining an "asthma action plan" for each affected child, shared throughout the community, including through the patient portal. Diabetes management introduced patient treatment decision tools and patient quality of life measures, facilitating care. Influenza vaccination was enhanced by large-scale community reporting in partnership with the state vaccination registry. The methodology and principles for arriving at these solutions included community engagement, sustainability, scalability, standards, and best practices that fit a variety of organizations-from large, robust providers to small organizations. FINDINGS: The SE Minnesota Beacon demonstrated that all providers for a geographically defined population can cooperate in the development and shared governance of a low-cost, sustainable HIE, and the operation of a community-managed clinical data repository. Furthermore, these infrastructures can be leveraged to collaboratively improve the care of patients, as demonstrated for childhood asthma and adult diabetes mellitus. CONCLUSION: The shared governance of HIT by a community can palpably change the scope and success of collaborations targeted to improve patient and community health care.

Latent factor structure of the Test of Memory and Learning in a pediatric traumatic brain injured sample: support for a general memory construct.

The Test of Memory and Learning (TOMAL; Reynolds, C. R., & Bigler, E. D. (1994a). Test of Memory and Learning (TOMAL). Austin, Texas: Pro-Ed; Reynolds, C. R., & Bigler, E. D. (1994b). Test of Memory and Learning (TOMAL): Examiner's manual. Austin, Texas: Pro-Ed) was published to ameliorate the paucity of developmentally appropriate instruments for the assessment of memory in children and adolescents. No studies have confirmed the latent factor structure of the TOMAL. Two structural models were subjected to confirmatory factor analysis using the TOMAL performances of 140 subjects, age 5-19, with traumatic brain injury (TBI). Model 1 was a four-factor model with a large "Complex Memory" factor and three smaller factors. Model 2 was a two-factor model with Verbal and Nonverbal Memory factors, both of which loaded on a second-order "General" memory factor. Results indicated that the model with a higher order structure demonstrated better fit than the four-factor model. Further analysis suggested that the TOMAL factor structure is characterized by a large Complex Memory and smaller, Sustained Attention factor. The study provides tentative support for a "general memory" construct.