Should I See You Again Soon? A Multispecialty Assessment of the Impact and Burden of Preoperative History and Physical Update Visits.

BACKGROUND: Federal regulations require a history and physical (H&P) update performed ≤30 days before a planned procedure. We evaluated the utility and burdens of H&P update visits by determining impact on operative management, suitability for telehealth, and visit time and travel burden. STUDY DESIGN: We identified H&P update visits performed in our health system during 2019 for 8 surgical specialties. As available, up to 50 visits per specialty were randomly selected. Primary outcomes were a) interval changes in history, exam, or operative plan between the initial and updated H&P notes and b) visit suitability for telehealth, as determined by two independent physician reviewers. Clinic time was captured, and round-trip driving time and distance between patients' home and clinic ZIP codes were estimated. RESULTS: We identified 8,683 visits and 362 were randomly selected for review. Documented changes were most commonly identified in histories (60.8%), but rarely in physical exams (11.9%) and operative plans (11.6%). 99.2% of visits were considered suitable for telehealth. Median clinic time was 52 minutes (IQR:33.8-78), driving time was 55.6 minutes (IQR:35.5-85.5), and driving distance was 20.2 miles (IQR:8.5-38.4). At the health system level, patients spent an estimated aggregate 7,000 hours (including 4,046 hours of waiting room and travel time) and drove 142,273 miles to attend in-person H&P update visits in 2019. CONCLUSION: Given their minimal impact on operative management, regulatory requirements for in-person H&P updates should be reconsidered. Flexibility in update timing and modality might help defray the substantial burdens these visits impose on patients.

The Device for Intraventricular Entry guide: a novel solution to a perpetual problem.

OBJECTIVE: The authors designed a low-profile device for reliable ventricular access and prospectively studied its safety, efficacy, and accuracy at a large academic center. METHODS: A novel device for ventricular entry, the Device for Intraventricular Entry (DIVE) guide, was designed and created by the first and senior authors. Fifty patients undergoing external ventricular drainage (EVD) or shunt placement were prospectively enrolled for DIVE-assisted catheter placement at a single academic center. The primary outcome was the catheter tip location on postprocedural CT. Secondary outcomes included number of catheter passes, clinically significant hemorrhages, and procedure-related infections. RESULTS: Fifty patients were enrolled. Indications included subarachnoid hemorrhage, intraventricular hemorrhage, traumatic brain injury, hydrocephalus, pseudotumor, and postsurgical wound drainage. In total, 76% (38/50) of patients underwent right-sided placement and 24% (12/50) underwent left-sided placement. All 100% (50/50) of patients had successful cannulation with an average of 1.06 passes. Postprocedural head CT confirmed ipsilateral frontal horn or third ventricle placement (Kakarla grade 1) in 92% (46/50) of patients and placement in the contralateral lateral ventricle in 8% (4/50) (Kakarla grade 2). There were no clinically significant track hemorrhages or procedural infections. CONCLUSIONS: This single-center prospective study investigated the safety and efficacy of DIVE-assisted ventricular access. In total, 100% of procedures had successful ventricular cannulation, with 92% achieving Kakarla grade 1, with an average of 1.06 passes without any clinical complications.

Early Shared Decision-Making for Older Adults with Traumatic Brain Injury: Using Time-Limited Trials and Understanding Their Limitations.

Older adults account for a disproportionate share of the morbidity and mortality after traumatic brain injury (TBI). Predicting functional and cognitive outcomes for individual older adults after TBI is challenging in the acute phase of injury. Given that neurologic recovery is possible and uncertain, life-sustaining therapy may be pursued initially, even if for some, there is a risk of survival to an undesired level of disability or dependence. Experts recommend early conversations about goals of care after TBI, but evidence-based guidelines for these discussions or for the optimal method for communicating prognosis are limited. The time-limited trial (TLT) model may be an effective strategy for managing prognostic uncertainty after TBI. TLTs can provide a framework for early management: specific treatments or procedures are used for a defined period of time while monitoring for an agreed-upon outcome. Outcome measures, including signs of worsening and improvement, are defined at the outset of the trial. In this Viewpoint article, we discuss the use of TLTs for older adults with TBI, their potential benefits, and current challenges to their application. Three main barriers limit the implementation of TLTs in these scenarios: inadequate models for prognostication; cognitive biases faced by clinicians and surrogate decision-makers, which may contribute to prognostic discordance; and ambiguity regarding appropriate endpoints for the TLT. Further study is needed to understand clinician behaviors and surrogate preferences for prognostic communication and how to optimally integrate TLTs into the care of older adults with TBI.

Preoperative Predictors of Survival in Patients With Spinal Metastatic Disease.

BACKGROUND: There remains a number of factors thought to be associated with survival in spinal metastatic disease, but evidence of these associations is lacking. In this study, we examined factors associated with survival among patients undergoing surgery for spinal metastatic disease. METHODS: We retrospectively examined 104 patients who underwent surgery for spinal metastatic disease at an academic medical center. Of those patients, 33 received local preoperative radiation (PR) and 71 had no PR (NPR). Disease-related variables and surrogate markers of preoperative health were identified, including age, pathology, timing of radiation and chemotherapy, mechanical instability by spine instability neoplastic score, American Society of Anesthesiologists (ASA) classification, Karnofsky performance status (KPS), and body mass index (BMI). We performed survival analyses using a combination of univariate and multivariate Cox proportional hazards models to assess significant predictors of time to death. RESULTS: Local PR (Hazard Ratio [HR] = 1.84, P = 0.034), mechanical instability (HR = 1.11, P = 0.024), and melanoma (HR = 3.60, P = 0.010) were significant predictors of survival on multivariate analysis when controlling for confounders. PR vs NPR cohorts exhibited no statistically significant differences in preoperative age (P = 0.22), KPS (P = 0.29), BMI (P = 0.28), or ASA classification (P = 0.12). NPR patients had more reoperations for postoperative wound complications (11.3% vs 0%, P < 0.001). CONCLUSIONS: In this small sample, PR and mechanical instability were significant predictors of postoperative survival, independent of age, BMI, ASA classification, and KPS and in spite of fewer wound complications in the PR group. It is possible that PR was a surrogate of more advanced disease or poor response to systemic therapy, independently portending a worse prognosis. Future studies in larger, more diverse populations are crucial for understanding the relationship between PR and postoperative outcomes to determine the optimal timing for surgical intervention. CLINICAL RELEVANCE: These findings are clinically relevent as they provide insight into factors associated with survival in metastatic spinal disease.

Allograft nerve repair to prevent sensorimotor loss after nerve sheath tumor resection.

Acellularized nerve allografts (ANAs) have been developed as substitutes for nerve autograft to promote nerve regeneration after surgical repair. In this video, the authors demonstrate operative techniques for using ANAs to repair potentially functional nerve fascicles during tumor resection. A 67-year-old female with schwannomatosis requested resection of a painful enlarging mass of the left ulnar nerve proximal to the elbow. During surgery, neuromonitoring suggested that fascicles entering the tumor could be functional. Therefore, nerve allograft was used to repair the transected fascicles. The patient recovered with full strength and sensation in the ulnar distribution, with resolution of her preoperative symptoms. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22101.

Oberlin transfer for C5-6 palsy after posterior cervical spine surgery.

Postoperative C5-6 palsies can occur in 5%-10% of cases after cervical spine surgery. In this video, the authors demonstrate operative techniques for nerve transfer to restore function for postoperative C5-6 palsy. The patient underwent C3-6 laminectomy and posterior fusion for cervical spondylotic myelopathy and developed weakness postoperatively in the C5-6 distribution bilaterally. He experienced spontaneous recovery to near full strength in the most affected muscle groups by 12 months except the left biceps (2/5), with at least antigravity shoulder abduction. He underwent left ulnar to musculocutaneous nerve fascicular transfer to improve elbow flexion and supination in the setting of good hand function. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22100.

Implementation of a Streamlined Care Pathway to Reduce Cost and Length of Stay for Patients Undergoing Endoscopic Transsphenoidal Pituitary Surgery.

BACKGROUND: We implemented a streamlined care pathway for patients undergoing endoscopic transsphenoidal (TSA) pituitary surgery. Select patients are recovered in the postanesthesia care unit and transferred to a step-down unit for intermediate neurologic care (INCU), with clinicians trained to manage cerebrospinal fluid leak, diabetes insipidus (DI), and other complications. METHODS: We evaluated all TSA surgeries performed at 1 academic medical center from 7th January, 2017 to 30th March, 2020, collecting patient factors, tumor characteristics, cost variables, and outcomes. The INCU pathway was implemented on 7th January 2018. Pathway patients were compared with nonpathway patients across the study period. Outcomes were assessed using multivariate regression, adjusting for patient and surgical characteristics, including intraoperative cerebrospinal fluid leak, postoperative DI, and tumor dimensions. RESULTS: One hundred eighty-seven patients were identified. Seventy-nine were on the INCU pathway. Mean age was 53.5 years. Most patients were male (66%), privately insured (62%), and white (66%). Mean total cost of admission was $27,276. Mean length of stay (LOS) was 3.97 days. Use of the INCU pathway was associated with total cost reduction of $6376.33 (P < 0.001, 95% confidence interval [CI]: $3698.21-$9054.45) and LOS reduction by 1.27 days (P = 0.008, 95% CI: 0.33-2.20). In-hospital costs were reduced across all domains, including $1964.87 in variable direct labor costs (P < 0.001, 95% CI: $1142.08-$2787.64) and $1206.52 in variable direct supply costs (P < 0.001, 95% CI: $762.54-$1650.51). Pathway patients were discharged earlier despite a higher rate of postoperative DI (25% vs. 11%, P = 0.011), with fewer readmissions (0% vs. 6%, P = 0.021). CONCLUSIONS: A streamlined care pathway following TSA surgery can reduce in-hospital costs and LOS without compromising patient outcomes.

Prediction of intracranial pressure crises after severe traumatic brain injury using machine learning algorithms.

OBJECTIVE: Avoiding intracranial hypertension after traumatic brain injury (TBI) is a foundation of neurocritical care, to minimize secondary brain injury related to elevated intracranial pressure (ICP). However, this approach at best is reactive to episodes of intracranial hypertension, allowing for periods of elevated ICP before therapies can be initiated. Accurate prediction of ICP crises before they occur would permit clinicians to implement preventive strategies, minimize total time with ICP above threshold, and potentially avoid secondary injury. The objective of this study was to develop an algorithm capable of predicting the onset of ICP crises with sufficient lead time to enable application of preventative therapies. METHODS: Thirty-six patients admitted to a level I trauma center with severe TBI (Glasgow Coma Scale score < 8) between April 2015 and January 2019 who underwent continuous intraparenchymal ICP monitor placement were retrospectively identified. Continuous ICP data were extracted from each monitoring period (range 4-96 hours of monitoring). An ICP crisis was treated as a binary outcome, defined as ICP > 22 mm Hg for at least 75% of the data within a 5-minute interval. ICP data preceding each ICP crisis were grouped into four total data sets of 1- and 2-hour epochs, each with 10- to 20-minute lead-time intervals before an ICP crisis. Crisis and noncrisis events were identified from continuous time-series data and randomly split into 70% for training and 30% for testing, from a subset of 30 patients. Machine learning algorithms were trained to predict ICP crises, including light gradient boosting, extreme gradient boosting, and random forest. Accuracy and area under the receiver operating characteristic curve (AUC) were measured to compare performance. The most predictive algorithm was optimized using feature selection and hyperparameter tuning to avoid overfitting, and then tested on a validation subset of 5 patients. Precision, recall, F1 score, and accuracy were measured. RESULTS: The random forest model demonstrated the highest accuracy (range 0.82-0.88) and AUC (range 0.86-0.88) across all four data sets. Further validation testing revealed high precision (0.76), relatively low recall (0.46), and overall strong predictive performance (F1 score 0.57, accuracy 0.86) for ICP crises. Decision curve analysis showed that the model provided net benefit at probability thresholds above 0.1 and below 0.9. CONCLUSIONS: The presented model can provide accurate and timely forecasts of ICP crises in patients with severe TBI 10-20 minutes prior to their occurrence. If validated and implemented in clinical workflows, this algorithm can enable earlier intervention for ICP crises, more effective treatment of intracranial hypertension, and potentially improved outcomes following severe TBI.

In-Hospital Cost Comparison for Open Versus Endoscopic Endonasal Approach for Meningioma Resection.

OBJECTIVE: To determine the in-hospital cost implications of an endoscopic expanded endonasal approach (EEEA) for meningioma resection relative to the open transcranial approach. METHODS: All anterior skull base meningioma surgeries performed over a period from January 1st, 2015 to October 31th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using R software. All cost data were converted into August 2021-equivalent dollar amounts using the United States Bureau of Labor Statistics consumer price index. RESULTS: Thirty-five patients met study criteria, including 27 patients undergoing an open transcranial approach and 8 undergoing an EEEA. Average length of stay for patients undergoing an open approach was 9.3 days compared to 5.6 within the EEEA group (P = .126). The average total in-hospital cost of patient undergoing an EEEA was $35417.1 compared to $46406.9 among patients undergoing an open transcranial approach (P = .168). On univariate analysis, the cost of an open transcranial approach relative to the EEEA was $10989.8 (P = .411). CONCLUSIONS: The open transcranial approach remained the dominant surgical approach to anterior skull base meningiomas over our study time period. However, despite limited patient numbers the EEEA was associated with decreased total in-hospital costs.

In-Hospital Costs for Open versus Endoscopic Endonasal Approach for Craniopharyngioma Resection.

OBJECTIVE: To determine the in-hospital cost implications of an expanded endoscopic endonasal approach (EEEA) for craniopharyngioma resection relative to the traditional open transcranial approach. METHODS: All craniopharyngioma surgeries performed at a single institution over a period from January 1st 2001 to October 31th 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate regression analysis was performed using R software. RESULTS: Thirty-six patients met study criteria, including 22 undergoing an open approach and 14 undergoing an EEEA. There was a significantly longer average length of stay among patients undergoing open resection (21.5 vs. 10.6 days, p = 0.024). The average total in-hospital cost of a patient undergoing an EEEA was $58979.3 compared to $89142.3 for an open approach (p = 0.127). On univariate regression analysis, the total in-hospital cost for a patient undergoing an open approach relative to an EEEA was $30163.0 (p = 0.127). The open approach was exclusively performed from study onset until April 2010 (16 patients). From April 2010 to August 2013, 6 open approaches and 5 EEEA were performed. The EEEA has been exclusively performed from August 2013 until the conclusion of our study period (9 patients). CONCLUSIONS: There has been a shift toward surgical resection of craniopharyngioma via an EEEA approach for amenable tumors. Our study demonstrates that the EEEA has become the preferred surgical approach at our institution, and shows that the EEEA is associated with shorter postoperative length of stay and lower total in-hospital cost. Laryngoscope, 133:83-87, 2023.

Case Report: Multilevel Ossification of the Ligamentum Flavum in a Patient With Spinal Osteoblastoma.

Introduction: Spinal osteoblastomas are primary benign bone tumors most commonly presenting as diffuse back pain in young adults. Rarely, spinal osteoblastoma is associated with ossification of the ligamentum flavum (OLF), a form of ectopic bone formation, which can present with myelopathy. This report highlights a unique case of a patient with spinal osteoblastoma, associated OLF, and thoracic myelopathy. Case Description: The patient presented with subtle myelopathy consisting of mid-thoracic back pain, paresthesias, and gait instability. Imaging findings were suggestive of spinal osteoblastoma with multifocal OLF. The patient was consented for thoracic decompression and stabilization at the T6-10 levels. Histopathology confirmed osteoblastoma with associated OLF. At follow up, the patient's neurological symptoms had completely resolved. Conclusion: This case describes management for a rare presentation of osteoblastoma with associated OLF and myelopathy. Surgeons should be wary of disproportionate neurological compromise when spinal osteoblastoma is associated with OLF. Further study is required to elucidate the pathogenesis of this condition.

Using Natural Language Processing to Classify Serious Illness Communication with Oncology Patients.

One core measure of healthcare quality set forth by the Institute of Medicine is whether care decisions match patient goals. High-quality "serious illness communication" about patient goals and prognosis is required to support patient-centered decision-making, however current methods are not sensitive enough to measure the quality of this communication or determine whether care delivered matches patient priorities. Natural language processing (NLP) offers an efficient method for identification and evaluation of documented serious illness communication, which could serve as the basis for future quality metrics in oncology and other forms of serious illness. In this study, we trained NLP algorithms to identify and characterize serious illness communication with oncology patients.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection.

Objectives The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design This is a retrospective regression analysis. Setting This study was done at a single, multihospital, urban academic medical center. Participants Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p = 0.015) and reoperation after index admission ( p = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p = 0.045) and decreasing but not significant reoperation after index admission ( p = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

The role of socioeconomic status on outcomes following cerebellopontine angle tumor resection.

PURPOSE: It is well documented that the interaction between many social factors can affect clinical outcomes. However, the independent effects of economics on outcomes following surgery are not well understood. The goal of this study is to investigate the role socioeconomic status has on postoperative outcomes in a cerebellopontine angle (CPA) tumor resection population. MATERIALS AND METHODS: Over 6 years (07 June 2013 to 24 April 2019), 277 consecutive CPA tumor cases were reviewed at a single, multihospital academic medical center. Patient characteristics obtained included median household income, Charlson Comorbidity Index (CCI), race, BMI, tobacco use, amongst 23 others. Outcomes studied included readmission, ED evaluation, unplanned return to surgery (during and after index admission), return to surgery after index admission, and mortality within 90 days, in addition to reoperation and mortality throughout the entire follow-up period. Univariate analysis was conducted amongst the entire population with significance set at a p value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (Q1) and highest (Q4) socioeconomic quartiles, with significance set at a p value <0.05. Stepwise regression was conducted to determine the correlations amongst study variables and identify confounding factors. RESULTS: Regression analysis of 273 patients did not find household income to be associated with any of the long-term outcomes assessed. Similarly, a Q1 vs Q4 comparison did not yield significantly different odds of outcomes assessed. CONCLUSION: Although not statistically significant, the odds ratios suggest socioeconomic status may have a clinically significant effect on postsurgical outcomes. Further studies in larger, matched populations are necessary to validate these findings.

Serious Illness Communication Practices in Glioblastoma: An Institutional Perspective.

Background: Early, high-quality advance care planning discussions are essential for supporting goal-concordant care among glioblastoma (GBM) patients. Objective: Using mixed methods, we sought to characterize current serious illness (SI) communication practices at our institution. Methods: The electronic medical records of 240 deceased GBM patients cared for at the Abramson Cancer Center in Philadelphia, PA between 2017 and 2019 were systematically reviewed for documented SI conversations about four domains: prognosis, goals, end-of-life planning, and code status. Patient outcomes and SI conversation characteristics were analyzed using descriptive statistics. Standardized interviews about GBM care were held with five clinicians. Interview transcripts were analyzed using grounded-theory coding to identify emergent themes. Results: Nearly all patients (96%) had at least one documented SI conversation (median: 4, interquartile range [IQR] 2-7), mostly outpatient with medical oncology physicians. Median timing of first SI conversation was 360 days before death. SI conversations were not significantly associated with patient outcomes, including inpatient death and hospice enrollment. Seven themes emerged from clinician interviews: balancing hope and reality, anticipatory guidance, neglect of the "big picture," need for earlier conversations, care coordination, the role of clinical expertise, and communication training. Conclusion: SI conversations were documented early and often in our sample, but their quality was difficult to assess. Contrary to our quantitative findings, interviewees reported that SI conversations were late, infrequent, inadequate, and fragmented across specialties, failing to explore critical issues such as prognosis and functional decline.

Resecting the dominant lesion: Patient outcomes after surgery and radiosurgery vs stand-alone radiosurgery in the setting of multiple brain metastases.

BACKGROUND: Brain metastases are the most common central nervous system (CNS) tumors, occurring in 300,000 people per year in the US. While there are immediate local benefits to surgical resection for dominant lesions, including reduction of tumor burden and edema, the survival benefits of surgical resection, over radiosurgery, remains unclear. METHODS: The University of Pennsylvania Health System database was retrospectively reviewed for patients presenting with multiple brain metastases from 1/1/16-8/31/18 with one dominant lesion > 2 cm in diameter, who underwent initial treatment with either resection of the dominant lesion or Gamma Knife radiosurgery (GKS). Inclusion criteria were age > 18, > 1 brain metastasis, and presence of a dominant lesion (>2 cm). We analyzed factors associated with mortality. RESULTS: 129 patients were identified (surgery=84, GKS=45). The median number of intracranial metastases was 3 (IQR: 2-5). The median diameter of the largest lesion was 31 mm (IQR: 25-38) in the surgery group vs 21 mm (IQR: 20-24) in the GKS group (p < 0.001). Mortality did not differ between surgery and GKS patients (69.1% vs 77.8%, p = 0.292). In a multivariate survival analysis, there was no difference in mortality between the surgery and GKS cohorts (aHR: 1.35, 95% CI: 0.74-2.45 p = 0.32). Pre-operative KPS (aHR: 0.97, 95% CI: 0.95-0.99, p = 0.004), CNS radiotherapy (aHR: 0.33, 95% CI: 0.19-0.56 p < 0.001), chemotherapy (aHR: 0.27, 95% CI: 0.15-0.47, p < 0.001), and immunotherapy (aHR: 0.41, 95% CI: 0.25-0.68, p = 0.001) were associated with decreased mortality. CONCLUSION: In our institution, patients with multiple brain metastases and one symptomatic dominant lesion demonstrated similar survival after GKS when compared with up-front surgical resection of the dominant lesion.