Milestones for neurosurgery sub-interns: a novel evaluation tool to quantitatively differentiate residency applicants.

OBJECTIVE: The study objective was to create a novel milestones evaluation form for neurosurgery sub-interns and assess its potential as a quantitative and standardized performance assessment to compare potential residency applicants. In this pilot study, the authors aimed to determine the form's interrater reliability, relationship to percentile assignments in the neurosurgery standardized letter of recommendation (SLOR), ability to quantitatively differentiate tiers of students, and ease of use. METHODS: Medical student milestones were either adapted from the resident Neurological Surgery Milestones or created de novo to evaluate a student's medical knowledge, procedural aptitude, professionalism, interpersonal and communication skills, and evidence-based practice and improvement. Four milestone levels were defined, corresponding to estimated 3rd-year medical student through 2nd-year resident levels. Faculty and resident evaluations as well as student self-evaluations were completed for 35 sub-interns across 8 programs. A cumulative milestone score (CMS) was computed for each student. Student CMSs were compared both within and between programs. Interrater reliability was determined with Kendall's coefficient of concordance (Kendall's W). Student CMSs were compared against their percentile assignments in the SLOR using analysis of variance with post hoc testing. CMS-derived percentile rankings were assigned to quantitatively distinguish tiers of students. Students and faculty were surveyed on the form's usefulness. RESULTS: The average faculty rating overall was 3.20, similar to the estimated competency level of an intern. Student and faculty ratings were similar, whereas resident ratings were lower (p < 0.001). Students were rated most highly in coachability and feedback (3.49 and 3.67, respectively) and lowest in bedside procedural aptitude (2.90 and 2.85, respectively) in both faculty and self-evaluations. The median CMS was 26.5 (IQR 21.75-29.75, range 14-32) with only 2 students (5.7%) achieving the highest rating of 32. Programs that evaluated the most students differentiated the highest-performing students from the lowest by at least 13 points. A program with 3 faculty raters demonstrated scoring agreement across 5 students (p = 0.024). The CMS differed significantly between SLOR percentile assignments, despite 25% of students being assigned to the top fifth percentile. CMS-driven percentile assignment significantly differentiated the bottom, middle, and top third of students (p < 0.001). Faculty and students strongly endorsed the milestones form. CONCLUSIONS: The medical student milestones form was well received and differentiated neurosurgery sub-interns both within and across programs. This form has potential as a replacement for numerical Step 1 scoring as a standardized, quantitative performance assessment for neurosurgery residency applicants.

National trends in the surgical management of metastatic lung cancer to the spine using the national inpatient sample database from 2005 to 2014.

Optimal management of metastatic lung cancer to the spine (MLCS) incorporates a multidisciplinary approach. With improvements in lung cancer screening andnonsurgical treatment, the role for surgerymay be affected. The objective of this study is to assess trends in the surgical management of MLCS using the National Inpatient Sample (NIS) database. The NIS was queried for patients with MLCS who underwent surgery from 2005 to 2014. The frequencies of spinal decompression alone, spinal stabilization with or without (+/-) decompression, and vertebral augmentation were calculated. Statistical analysis was performed to analyze the effect of patient characteristics on outcomes. The most common procedure performed was vertebral augmentation (10719, 44.3%), followed by spinal stabilization +/- decompression (8634, 35.7%) and then decompression alone (4824, 20.0%). The total number of surgeries remained stable, while the rate of spinal stabilizations increased throughout the study period (p < 0.001). Invasive procedures such as stabilization and decompression were associated with greater costs, length of stay,complications and mortality. Increasingcomorbidity was associated with increased odds of complication, especially in patients undergoing more invasive procedures. In patients with lowpre-operative comorbidity, the type of procedure did not influence the odds of complication. Graded increases in length of stay, cost and mortality were seen with increasing complication rate.The rate of spinal stabilizations increased, which may be due to either increased early detection of disease facilitating use of outpatient vertebral augmentation procedures and/or the recognition that surgical decompression and stabilization are necessary for optimal outcome in the setting of MLCS with neurological deficit.

Current trends in incidence, characteristics, and surgical management of metastatic breast cancer to the spine: A National Inpatient Sample analysis from 2005 to 2014.

Management of metastatic breast cancer to the spine (MBCS) incorporates a multimodal approach. Improvement in screening and nonsurgical therapies may alter the trends in surgical management of MBCS. The objective of this study is to assess trends in surgical management of MBCS and short-term outcomes based on the National Inpatient Sample (NIS) database. The NIS database was queried for patients with MBCS who underwent surgery from 2005 to 2014. The weighted frequencies of spinal decompression alone, spinal stabilization +/- decompression, and vertebral augmentation were calculated. Multivariate analysis was performed to analyze the effect of patient characteristics on outcomes stratified by procedure. The most common procedure performed was vertebral augmentation (11,114, 53.4%), followed by stabilization +/- decompression (6,906, 33.2%) and then decompression alone (3,312, 13.4%). The total population-adjusted rate of surgical management for MBCS remained stable, while the rate of spinal stabilization increased (P < 0.001) and vertebral augmentation decreased (p < 0.003). The risk of complication increased with spinal stabilization and decompression compared to vertebral augmentation procedures in those with fewer comorbidities. This relative increase in risk abated in patients with higher numbers of pre-operative comorbidities. Any single complication was associated with increases in length of stay, cost, and mortality. The rate of in-hospital interventions remained stable over the study period. Stratified by procedure, the rate of stabilizations increased with a concomitant decrease in vertebral augmentations, which suggests that patients who require hospitalization for MBCS are becoming more likely to represent advanced cases that are not amenable to palliative vertebral augmentation procedures.

Factors associated with length of stay after single-level posterior thoracolumbar instrumented fusion primarily for degenerative spondylolisthesis.

BACKGROUND: The postoperative length of stay (LOS) is an important prognostic indicator for patients undergoing instrumented spinal fusion surgery. Increased LOS can be associated with higher infection rates, higher incidence of venous thromboembolisms, and a greater frequency of hospital-acquired delirium. The day of surgery and early postoperative mobilization following single-level posterior thoracolumbar stabilizations may impact the LOS. In this study, we evaluated the effects of weekday (Monday-Thursday) versus weekend (Friday-Sunday) surgery and postoperative rehabilitation services on LOS following primarily transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis (DS). METHODS: In this single-institution retrospective chart review, we identified 198 adults who received a one-level thoracolumbar instrumented fusion through a posterior only approach (2017-2019). The majority of these patients underwent TLIF for DS. A zero truncated negative binomial model was used for predictors of the primary outcome of LOS (weekday of surgery, duration of operation, first or repeat surgery, and physical therapy/ occupational therapy [PT/OT] evaluation). Covariates were sex, age, and body mass index. RESULTS: We found that operative duration, repeat surgery, and in-hospital PT/OT all significantly increased the LOS (P < 0.05). Furthermore, those undergoing weekday surgery (Monday-Thursday) had 1.29 times longer LOS than those on the weekend (Friday-Sunday), but this did not reach statistical significance (P = 0.09). CONCLUSION: In our patient sample, duration, repeat surgery, and in-hospital PT/OT increased the LOS following primarily TLIF for DS. The increased LOS in these cases is likely due to higher overall disease burden and case complexity. In addition, those patients with a greater likelihood of extended recovery and ongoing neurologic deficits are more likely to have PT/OT evaluations. Notably, LOS was not significantly impacted by the day of surgery at our institution.

Changes in the Operative Corridor in Oblique Lumbar Interbody Fusion Between Preoperative Magnetic Resonance Imaging and Intraoperative Cone-Beam Computed Tomography Using Morphometric Analysis.

Background The oblique lumbar interbody fusion or anterior-to-psoas (OLIF/ATP) technique relies on a corridor anterior to the psoas and posterior to the vasculature for lumbar interbody fusion. This is evaluated preoperatively with CT and/or MRI. To date, there have been no studies examining how intraoperative, lateral decubitus positioning may change the dimensions of this corridor when compared to preoperative imaging. Objective Our objective was to evaluate changes in the intraoperative corridor in the supine and lateral positions utilizing preoperative and intraoperative imaging. Methods We performed a retrospective analysis among patients who have undergone an OLIF/ATP approach at two tertiary care centers from 2016 to 2018 by measuring the distance between the left lateral border of the aorta or iliac vessels and anteromedial border of the psoas muscle from L1-L2 through L4-5 disc spaces. We compared this corridor between supine, preoperative MRI axial and intraoperative CT acquired in the right lateral decubitus position. Results Thirty-three patients, 15 of whom were female, were included in our study. The average age of the patients was 65.4 years and the average BMI was 31 kg/m2. The results revealed a statistically significant increase (p<.05) in the intraoperative corridor from supine to lateral decubitus positioning at all levels. However, age, BMI, and gender had no statistically significant impact on the preoperative versus intraoperative corridor. Conclusion This is the first study to provide objective evidence that lateral decubitus positioning increases the intraoperative corridor for OLIF/ATP. Our study demonstrates that lateral decubitus positioning provides a more favorable corridor for the OLIF/ATP technique from L1-L5 disc levels.

Concussions: What a neurosurgeon should know about current scientific evidence and management strategies.

BACKGROUND: There has been a tremendous amount of interest focused on the topic of concussions over the past few decades. Neurosurgeons are frequently consulted to manage patients with mild traumatic brain injuries (mTBI) that have radiographic evidence of cerebral injury. These injuries share significant overlap with concussions, injuries that typically do not reveal radiographic evidence of structural injury, in the realms of epidemiology, pathophysiology, outcomes, and management. Further, neurosurgeons often manage patients with extracranial injuries that have concomitant concussions. In these cases, neurosurgeons are often the only "concussion experts" that patients encounter. RESULTS: The literature has been reviewed and data have been synthesized on the topic including sections on historical background, epidemiology, pathophysiology, diagnostic advances, clinical sequelae, and treatment suggestions, with neurosurgeons as the intended target audience. CONCLUSIONS: Neurosurgeons should have a fundamental knowledge of the scientific evidence that has developed regarding concussions and be prepared to guide patients with treatment plans.

A multinomial-dirichlet model for analysis of competing hypotheses.

Analysis of competing hypothesis, a method for evaluating explanations of observed evidence, is used in numerous fields, including counterterrorism, psychology, and intelligence analysis. We propose a Bayesian extension of the methodology, posing the problem in terms of a multinomial-Dirichlet hierarchical model. The yet-to-be observed true hypothesis is regarded as a multinomial random variable and the evaluation of the evidence is treated as a structured elicitation of a prior distribution on the probabilities of the hypotheses. This model provides the user with measures of uncertainty for the probabilities of the hypotheses. We discuss inference, such as point and interval estimates of hypothesis probabilities, ratios of hypothesis probabilities, and Bayes factors. A simple example involving the stadium relocation of the San Diego Chargers is used to illustrate the method. We also present several extensions of the model that enable it to handle special types of evidence, including evidence that is irrelevant to one or more hypotheses, evidence against hypotheses, and evidence that is subject to deception.