Barriers to overlapping complex and general spine surgery at a tertiary academic hospital.

OBJECTIVE: Policy concern and debate surround the concept of overlapping spine surgery. Overlapping surgery specifically refers to nonessential portions of the case or noncutting time overlap. This differs from concurrent surgery, in which critical portions of the procedure overlap. Here the authors explore the barriers for safe and efficient overlapping surgery in academic spinal deformity practice. METHODS: Over a 24-month period, cases of spinal deformity, degenerative cases, anterior cervical discectomy and fusions (ACDFs), and laminectomy were reviewed for duration in operating room (OR) prior to surgery, duration of cutting time, duration in OR after surgery, turnover duration, and time delay from initial start time. Standard degenerative cases were referenced as 1-2 ACDFs as well as 1- to 2-level laminectomy surgery. The blocks of time between two consecutive cutting periods were investigated to determine the feasibility of overlapping an additional surgery. Specifically, the authors compared the blocks of time that include the postsurgery period, the turnover period, and the presurgery period to cutting periods. RESULTS: One hundred twenty-six complex spinal deformity procedures and 85 degenerative cases (including 49 ACDFs and 36 laminectomies) from one center and one neurosurgeon were reviewed. These procedures were performed between September 2019 and December 2021 with a 3-month gap in military deployment. On average, the procedure's duration for cases of deformity was 236.5 minutes, for cases of ACDFs it was 84 minutes, and for cases of laminectomies it was 105.5 minutes. The block of noncutting time while the patient was in the OR showed no difference from the surgical cut time. The turnover time between cases was 52.35 minutes. Of 100 cases scheduled as the first case of the day, 94 had a delay to the OR averaging 18.2 minutes. CONCLUSIONS: The data in this study indicate that estimates for pre- and postsurgical times alone are not sufficient to allow for overlapping surgery. The average cut-time duration of ACDF was 84 minutes; the average presurgical time for deformity was 68 minutes. This highlights the critical analysis for further examination of optimal scheduling, on-time first start, turnover periods, and the orchestration of all members of the providing team to optimize the cutting time for safe and consistent implementation of overlapping spine surgery.

State-to-State Variation in Medicaid Reimbursement for Neurosurgical Procedures: Implications for Healthcare Access in Vulnerable Populations.

BACKGROUND AND OBJECTIVES: Medicaid payment for healthcare services traditionally reimburses less than Medicare and commercial insurance. This disparity in reimbursement seems to be an important driver of limited access to care among Medicaid beneficiaries. This study seeks to examine the degree of variation in Medicaid and Medicare reimbursement for the most common neurosurgical current procedural terminology codes and determine its potential impact on provider accessibility. METHODS: In this cross-sectional study, maximum allowed physician reimbursement fees for 20 common neurosurgical codes reported in the literature were obtained from the 2022 Medicare Physician Fee Schedule and individual state Medicaid Fee-for-Service Schedules. The Medicaid-Medicare Index (MMI), which measures Medicaid reimbursement as a fraction of Medicare allowed amounts, was calculated for each procedure across 49 states and the District of Columbia. Lower MMI indicates a greater disparity, or "discount," between Medicaid and Medicare reimbursement. The proportion of providers accepting new Medicaid patients and total Medicaid enrollment were compared across states as a function of MMI. RESULTS: The average national MMI was 0.79, with a range of 0.37 in NY/NJ to 1.43 in NE. Maximum allowed amounts for Medicare reimbursement (coefficient of variation = 0.09) were less variable than those for Medicaid (coefficient of variation = 0.26, P < .01). The largest absolute disparity was observed for intracranial aneurysm clipping in NY, where the maximum Medicaid reimbursement is $3496.52 less than that of Medicare. Higher MMI was associated with a significantly larger proportion of providers accepting new Medicaid patients (R2 = 0.43, P < .01). Moreover, MMI varied inversely with the number of Medicaid beneficiaries (R2 = 0.12, P = .01). CONCLUSION: Medicaid reimbursement varies between states reflecting the disparate methods of fee schedule calculation. Lower reimbursement is associated with more limited provider enrollment, especially in states with a greater number of beneficiaries.

Neonatal Halter Traction for Severe Cervical Spine Deformity: A Technical Case Report With 2-Year Follow-up.

BACKGROUND AND IMPORTANCE: Although rare, severe congenital cervical spine deformity can present with limited treatment options and potentially catastrophic outcomes. The use of halter traction for cervical deformity correction in children has been well described, but it has not been previously reported in the management of neonates. CLINICAL PRESENTATION: A baby girl born at full-term gestation presented with generalized hypotonia, bilateral club feet, and significant right upper extremity weakness. Imaging demonstrated a severe congenital swan-neck deformity with spinal cord compression. Halter traction was initiated in the neonatal intensive care unit with subsequent neurological and radiographic improvement. After 7 days, traction was discontinued and she was placed in a custom-fitted cervico-thoracic orthosis. At 2 years of follow-up, she remains neurologically stable with maintained cervical alignment. CONCLUSION: Halter traction followed by external bracing is technically possible in the neonatal period. For children with severe cervical congenital deformity, this technique can reduce spinal cord compression, provide significant deformity correction, and delay the need for definitive operative spinal stabilization.

Lumbo-Pelvic Dissociation in a Patient With Complex Spinal Deformity: A Case Report.

Lumbopelvic dissociation is an extremely rare injury to the junction of the lumbar spine and sacrum seen in high-energy trauma, for which the operative treatment has not been established, especially in the setting of hardware infection. In this case report, we describe the case of a 37-year-old male who presented to the spine surgery team after undergoing six surgeries, all following a traumatic car accident ten years prior. The patient initially presented with symptomatic lumbar hyperlordosis that had progressively limited his ability to perform activities of daily living. He suffered from paraplegia and a sensory deficit at the T8 level and below but still maintained control over his bowel and bladder. The surgical team performed two operations: one to improve his quality of life by correcting the degree of lordosis he was suffering from due to a 76-degree sacral slope and the second to perform re-instrumentation after the patient suffered a traumatic injury three weeks after the initial operation that occurred after assisting with his own wheelchair transfers. His prior surgeries include operations for deformity correction as well as irrigation and debridement secondary to hardware infection and subsequent removal. He reported that following the hardware removal he had significant pain and was no longer able to easily sit and play with his child or reach countertops while in his wheelchair, severely impacting his quality of life. The surgical team performed two operations on this patient: the first to correct the lordotic deformity utilizing a four-rod construct, and a second performed three weeks later to perform re-instrumentation utilizing a five-rod construct and hematoma evacuation following hardware failure secondary to high biomechanical strain from performing his own wheelchair transfers.

Severe hypotension with loss of motor evoked potentials during cervical surgery prompting immediate cardiovascular resuscitation.

BACKGROUND: Intraoperative neuromonitoring (IONM) is a well-established adjunct to spinal surgery to ensure safety of the neural elements.IONM has extremely high sensitivity and specificity for impending neurologic damage. In very rare instances, hypoperfusion of the cord may lead to a loss of IONM modalities that may be reversed if blood pressure issues responsible for the drop out of potentials are immediately addressed. CASE DESCRIPTION: The authors describe a case in which IONM documented hypoperfusion of the cord intraoperatively due to hypotension. Recognition of this problem and reversal of the hypotension resulted in normalization of postoperative function. CONCLUSION: The use of IONM allowed for quick recognition of an impending neurological insult during spinal deformity surgery. Prompt response to signaling changes allowed for the correction of hypotension and favorable neurologic outcome.

Resection of congenital hemivertebra in pediatric scoliosis: the experience of a two-specialty surgical team.

OBJECTIVE: Institutions investigating value and quality emphasize utilization of two attending surgeons with different areas of technical expertise to treat complex surgical cases and to minimize complications. Here, the authors chronicle the 12-year experience of using a two-attending surgeon, two-specialty model to perform hemivertebra resection in the pediatric population. METHODS: Retrospective cohort data from 2008 to 2019 were obtained from the NewYork-Presbyterian Morgan Stanley Children's Hospital operative database. This database included all consecutive pediatric patients < 21 years old who underwent hemivertebra resection performed with the two-attending surgeon (neurosurgeon and orthopedic surgeon) model. Demographic information was extracted. Intraoperative complications, including durotomy and direct neurological injury, were queried from the clinical records. Intraoperative neuromonitoring data were evaluated. Postoperative complications were queried, and length of follow-up was determined from the clinical records. RESULTS: From 2008 to 2019, 22 patients with a median (range) age of 9.1 (2.0-19.3) years underwent hemivertebra resection with the two-attending surgeon, two-specialty model. The median (range) number of levels fused was 2 (0-16). The mean (range) operative time was 5 hours and 14 minutes (2 hours and 59 minutes to 8 hours and 30 minutes), and the median (range) estimated blood loss was 325 (80-2700) ml. Navigation was used in 14% (n = 3) of patients. Neither Gardner-Wells tongs nor halo traction was used in any operation. Neuromonitoring signals significantly decreased or were lost in 14% (n = 3) of patients. At a mean ± SD (range) follow-up of 4.6 ± 3.4 (1.0-11.6) years, 31% (n = 7) of patients had a postoperative complication, including 2 instances of proximal junctional kyphosis, 2 instances of distal junctional kyphosis, 2 wound complications, 1 instance of pseudoarthrosis with hardware failure, and 1 instance of screw pullout. The return to the operating room (OR) rate was 27% (n = 6), which included patients with the abovementioned wound complications, distal junctional kyphosis, pseudoarthrosis, and screw pullout, as well as a patient who required spinal fusion after loss of motor evoked potentials during index surgery. CONCLUSIONS: Twenty-two patients underwent hemivertebra resection with a two-attending surgeon, two-specialty model over a 12-year period at a specialized children's hospital, with a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and a 27% rate of unplanned return to the OR.

"There's got to be a better way": Global Perspectives of Medicolegal Environment and Neurosurgical Socioeconomics.

Neurosurgery is considered to have one of the greatest risks of medical malpractice claims. However, medicolegal issues in neurosurgery are often disregarded and underrated worldwide. Medical errors in the neurosurgical field can be attributed to multiple factors, including highly morbid pathologies, the technical difficulty of neurosurgical procedures, and the involvement and interaction of a multidisciplinary team in the care of neurosurgical patients. Health care providers worldwide are at risk of lawsuits, sometimes even when no deviation from the standard of care had occurred in a given case. Often, governments use additional tactics to decrease the burden on compensators and extrajudicial institutions and to decrease the court's flow of irrational litigation. Continuous amendments to health care acts and newer reforms to address these issues have materialized worldwide. In the present narrative review, we have reviewed the global perspectives of medicolegal issues, with a focus on neurosurgical discipline.

Neurosurgery Billing and Reimbursement in 2021.

Practicing neurosurgery in 2021 requires a detailed knowledge of the vocabulary and mechanisms for coding and reimbursement, which should include general knowledge at the global level and fluency at the provider level. It is specifically of interest for the neurosurgeon to understand conceptually the nuances of hospital reimbursement. That knowledge is especially germane as more neurosurgeons become hospital employees. Here we provide an overview of the mechanics of coding. We illustrate the formula to generate physician reimbursement through the current relative value unit structure. We also seek to explain hospital-level reimbursement through the diagnosis-related group structure. Finally, we expand about different and ancillary income streams available to neurosurgeons and provide a realistic assessment including the opportunities and challenges of those entities.

Socioeconomic Implications of Professional Relationships within Modern Care Delivery Systems.

No physician can successfully deliver high-value patient care in the modern-day health care system in isolation. Delivery of effective patient care requires integrated and collaborative systems that depend on dynamic professional relationships among members of the health care team. An overview of the socioeconomic implications of professional relationships within modern care delivery systems and potential employment models is presented.

Credentialing, Certification, and Peer Review Essentials for the Neurosurgeon.

Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries.

The Medical Legal Environment in Neurosurgery: An Informative Overview of the Stages of Litigation and Distinct Challenges.

Medical malpractice litigation is something that every neurosurgeon encounters in his or her career and causes significant strife to amateur physicians attempting to navigate the medicolegal process. Neurosurgery in particular is one of the highest risk specialties for litigation. This calls to order the importance of a clear understanding of the medicolegal proceedings that may follow after a complaint has been filed. This report describes the steps to be taken by the physician in the instance that litigation is expected or considered a possibility. We describe the elements that comprise a medical malpractice claim, details of the lawsuit process including hospital peer review and expert witness selection, and how to communicate appropriately with the patients and their families in an empathetic way. It is imperative to gain an appropriate understanding of the entirety of the malpractice claim process to ease the anxiety of litigation for the physician and decrease the amount of avoidable complications.

Neurosurgery and spinal adaptations in spaceflight: A literature review.

BACKGROUND: Spaceflight places astronauts in multiple environments capable of inducing pathological changes. Alterations in the spine have a significant impact on astronauts' health during and after spaceflight. Low back pain is an established and common intra-flight complaint. Intervertebral disc herniation occurs at higher rates in this population and poses significant morbidity. Morphological changes within intervertebral discs, vertebral bodies, and spinal postural muscles affect overall spine function and astronaut performance. There remains a paucity of research related to spaceflight-induced pathologies, and currently available reviews concern the central nervous system broadly while lacking emphasis on spinal function. OBJECTIVE: Our aim was to review and summarize available data regarding changes in spinal health with exposure to spaceflight, especially focusing on effects of microgravity. The authors also present promising diagnostic and treatment approaches wherein the neurosurgeon could positively impact astronauts' health and post-flight outcomes. MATERIALS AND METHODS: Articles included in this review were identified via search engine using MEDLINE, PubMed, Cochrane Review, Google Scholar, and references within other relevant articles. Search criteria included "spine and spaceflight", "vertebral column and spaceflight", "vertebral disc and spaceflight", and "muscle atrophy and spaceflight", with results limited to articles written in English from 1961 to 2020. References of selected articles were included as appropriate. RESULTS: Fifty-six articles were included in this review. Compositional changes at the intervertebral discs, vertebral bone, and paraspinal muscles contribute to undesirable effects on astronaut spinal function in space and contribute to post-flight pathologies. Risk of intervertebral disc herniation increases, especially during post-flight recovery. Vertebral bone degeneration in microgravity may increase risk for herniation and fracture. Paraspinal muscle atrophy contributes to low back pain, poorer spine health, and reduced stability. CONCLUSION: Anatomical changes in microgravity contribute to the development of spinal pathologies. Microgravity impacts sensory neurovestibular function, neuromuscular output, genetic expression, among other systems. Future developments in imaging and therapeutic interventions may better analyze these changes and offer targeted therapeutic interventions to decrease the burden of pain and other diseases of the spine in this population.

Neurological Manifestations of COVID-19 Within the Intensive Care Unit During a Military Deployment for the Early Pandemic Surge in New York City.

Coronavirus disease 2019 (COVID-19) resulted in a worldwide pandemic that at the time of this writing has caused over 400,000 deaths within the United States. During the pandemic surge in New York City, NY, a number of military Medical Corps (MC) and Nurse Corps (NC) providers were mobilized in direct support of critical care capabilities through expansion intensive care units. In the course of the deployment, high rates of neurological-related manifestations associated with COVID-19 infection were directly observed by our military provider teams which will be described and supporting literature highlighted. This is organic information absorbed in real time during the early stages of the pandemic in New York City. The neurological manifestations of COVID-19 varied in presentation and severity. Cerebral vascular injuries documented included strokes, iatrogenic intraparenchymal hemorrhage, hypoxia-related changes and sequelae, as well as acquired diseases secondary to delayed treatment of other primary neurologic disease states. Hypercoagulable and inflammatory markers (d-dimer, C-reactive protein, etc) were commonly elevated, and anticoagulation became a key factor in disease treatment and to help mitigate the downstream neurologic sequelae associated with this disease. Here we present these initial findings to lay the groundwork for more robust clinical studies moving forward.

L5 Vertebral Column Resection for Correction of Severe Lumbar Hyperlordosis and Pelvic Anteversion in an Adolescent With Prior Myelomeningocele Repair and Lumbar Fusion: Case Report.

BACKGROUND AND IMPORTANCE: Lumbar hyperlordosis in ambulatory children is an uncommon but potentially problematic spinal deformity, and the operative management has not been comprehensively described. CLINICAL PRESENTATION: We report the case of a 14-yr-old girl presenting with severe progressive lumbar hyperlordosis (-122°) and sagittal imbalance (-6 cm). She had multiple prior surgeries, including myelomeningocele repair at 10 d old, midlumbar meningioma resection at 8 mo old, and posterior lumbar instrumented spinal fusion at 5 yr old. She presented with progressive lumbosacral back pain and intermittent numbness in her left lower extremity, and severe skin contractures over her prior posterior incisions. From an all posterior approach, prior implants and dural scar were removed and then an L5 vertebral column resection (VCR) was performed to disarticulate her lumbar spine from her anteverted pelvis, allowing for slow distraction forces to correct her lumbar hyperlordosis. This was followed by a T7-sacrum fusion using pedicle screws and iliac screws, with autologous bone graft and plastic surgery wound closure. Postoperatively, lumbar lordosis was corrected to -55° and sagittal balance reduced to -0.5 cm. At 10-wk and 14-mo follow-ups, the patient reported resolution of her back pain with no limitations in physical activities. Dramatic improvement was seen in both her preoperative to 14-mo postoperative Oswestry Disability Index (ODI) (54 to 12) and Scoliosis Research Society Scoliosis Research Society (SRS)-22r (54 to 93) scores. CONCLUSION: This case highlights a rare presentation of severe progressive lumbar hyperlordosis in an ambulatory adolescent after myelomeningocele repair, meningioma resection, and posterior lumbar instrumented spinal fusion with subsequent surgical treatment incorporating important components of both spinal and plastic surgery involvement.

Complications in ambulatory pediatric patients with nonidiopathic spinal deformity undergoing fusion to the pelvis using the sacral-alar-iliac technique within 2 years of surgery.

OBJECTIVE: Significant investigation in the adult population has generated a body of research regarding proximal junctional kyphosis (PJK) and proximal junctional failure (PJF) following long fusions to the sacrum and pelvis. However, much less is known regarding early complications, including PJK and PJF, in the ambulatory pediatric patient. As such, the objective of this study was to address the minimal literature on early complications after ambulatory pediatric patients underwent fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac (S2AI) instrumentation. METHODS: The authors performed a retrospective review of pediatric patients with nonidiopathic spinal deformity < 18 years of age with ambulatory capacity who underwent fusion to the pelvis at a multisurgeon pediatric academic spine practice from 2016 to 2018. All surgeries were posterior-only approaches with S2AI screws as the primary technique for sacropelvic fixation. Descriptive, outcome, and radiographic data were obtained. The definition of PJF included symptomatic PJK presenting as fracture, screw pullout, or disruption of the posterior osseoligamentous complex. RESULTS: Twenty-five patients were included in this study. Nine patients (36.0%) had 15 complications for an overall complication rate of 60.0%. Unplanned return to the operating room occurred 8 times in 6 patients (24.0%). Four patients (16.0%) had wound issues (3 with deep wound infection and 1 with wound breakdown) requiring reoperation. Three patients (12.0%) had PJF, all requiring reoperation. A 16-year-old female patient with syndromic scoliosis underwent extension of fusion due to posterior tension band failure at 6 months. A 17-year-old male patient with neuromuscular scoliosis underwent extension of fusion due to proximal screw pullout at 5 months. A 10-year-old female patient with congenital scoliosis underwent extension for PJF at 5 months following posterior tension band failure. One patient had pseudarthrosis requiring reoperation 20 months postoperatively. CONCLUSIONS: Fixation to the pelvis enables significant deformity correction, but with rather high rates of complications and unexpected returns to the operating room. Considerations of sagittal plane dynamics for PJK and PJF should be strongly analyzed when performing fixation to the pelvis in ambulatory pediatric patients.

U.S. Neurosurgical Response to COVID-19: Forging a Path Toward Disaster Preparedness.

INTRODUCTION: The worldwide COVID-19 pandemic poses challenges to healthcare capacity and infrastructure. The authors discuss the structure and efficacy of the U.S. Navy's response to COVID-19 and evaluate the utility of this endeavor, with the objective of providing future recommendations for managing worldwide healthcare and medical operational demands from the perspective of Navy Neurosurgery. MATERIALS AND METHODS: The authors present an extensive review of topics and objectively highlight the efforts of U.S. Navy Neurosurgery as it pertains to the humanitarian mission during the COVID-19 pandemic. RESULTS: During the humanitarian mission (March 27, 2020-April 14, 2020), the response of active duty and reserve neurosurgeons in the U.S. Navy was robust. Neurosurgical coverage was present on board the U.S. Navy Ships Mercy and Comfort, with additional neurosurgical deployment to New York City for intensive care unit management and coverage. CONCLUSIONS: The U.S. Navy neurosurgical response to the COVID-19 pandemic was swift and altruistic. Although neurosurgical pathologies were limited among the presenting patients, readiness and manpower continue to be strong influences within the Armed Forces. The COVID-19 response demonstrates that neurosurgical assets can be rapidly mobilized and deployed in support of wartime, domestic, and global humanitarian crises to augment both trauma and critical care capabilities.

Advocacy to Government and Stakeholders.

Participation in the health care and government advocacy arena may represent new and challenging perspectives for the traditional neurosurgeon. However, those with a strong understanding of the laws, rules, regulations, and fiscal allocation process can directly influence the practice of neurosurgery in the United States. We seek to shine light on the black box of how health care laws are passed, the influence and techniques of lobbying, and the role and rules surrounding political action committees. This practical review of health care advocacy is supplemented by a blueprint for engagement in the political arena for the practicing neurosurgeon.