Spinal surgery and neurosurgeon: quo vadis?

The aim of this review was to point out some critical points in spinal surgery. We present a good idea dealing with the subspecialisation in neurosurgery. Spine surgery is a good and especially timely example for it. The technical progress in the discipline of spinal surgery since the catalytic advances of diagnostic imaging, our understanding of spinal biomechanics and bone growth physiology, and the development of spinal fixation instrumentation have allowed exponential growth in this field. As a result, there is an increasing interest in spinal surgery. In this paper, a Medline review of the literature was performed from 2000 to the present regarding spinal surgery. Today, there is an emerging field of "spine surgery" that incorporates both neurosurgery and orthopedic surgery. In the future, it is possible that there may be a well-defined medical specialty of "spine specialists" defined by its own board certification. This is not currently the case. In this paper, it was concluded that productive collegiality between neurosurgeon and orthopedic surgeon is necessary for the advancement of spine care. This could be to build an own specialisation of spinal surgery. But for that this speciality needs his own and common research, not a part done by neurosurgeons and one by orthopedic surgeons.

A new classification of complications in neurosurgery.

OBJECTIVE: To define and grade neurosurgical and spinal postoperative complications based on their need for treatment. METHODS: Complications were defined as any deviation from the normal postoperative course occurring within 30 days of surgery. A four-grade scale was proposed based on the therapy used to treat the complications: grade I, any non-life-threatening complications treated without invasive procedures; grade II, complications requiring invasive management such as surgical, endoscopic, and endovascular procedures; grade III, life-threatening adverse events requiring treatment in an intensive care unit (ICU); and grade IV, deaths as a result of complications. Each grade was classified as a surgical or medical complication. An observational test of this system was conducted between January 2008 and December 2009 in a cohort of 1190 patients at the Hospital Italiano de Buenos Aires. RESULTS: Of 167 complications, 129 (10.84%) were classified as surgical, and 38 (3.19%) were classified as medical complications. Grade I (mild) complications accounted for 31.73%, grade II (moderate) complications accounted for 25.74%, and grade III (severe) complications accounted for 34.13%. The overall mortality rate was 1.17%; 0.84% of deaths were directly related to surgical procedures. CONCLUSIONS: The authors present a simple, practical, and easy to reproduce way to report negative outcomes based on the therapy administered to treat a complication. The main advantages of this classification are the ability to compare surgical results among different centers and times, the ability to compare medical and surgical complications, and the ability to perform future meta-analyses.

Insuficiencia respiratoria por obstrucción de la vía aérea superior en el postoperatorio de la cirugía de columna cervical por vía anterior / Respiratory failure from upper airway collapse following anterior cervical spine surgery

OBJETIVOS: Determinar la frecuencia y las variables que predisponen a una obstrucción de la vía aérea superior en una serie de procedimientos quirúrgicos por vía anterior en la columna cervical. PACIENTES Y MÉTODOS: Revisión retrospectiva de 204 historias clínicas de pacientes operados de cirugía de columna cervical por vía anterior, por el servicio de neurocirugía, entre 2003 y 2009. Se recogieron las variables perioperatorias que pudieran influir en la aparición de obstrucción respiratoria de la vía aérea superior, el ingreso programado o no en la unidad de cuidados intensivos y el momento de aparición de la complicación. RESULTADOS: En 7 casos (3,4%) se produjo obstrucción parcial de la vía aérea superior, de los cuales 4 (1,9%) se resolvieron mediante intubación traqueal mientras que 3 (1,5%) requirieron una traqueostomía urgente. No hubo diferencias estadísticamente significativas entre las variables estudiadas y la aparición de obstrucción de la vía aérea superior en el postoperatorio. CONCLUSIONES: La obstrucción de la vía aérea superior asociada a la cirugía de columna cervical por vía anterior es una circunstancia inesperada, en la que además la valoración urgente de la vía aérea superior puede no coincidir con la realizada en la consulta preanestésica. En algunas ocasiones constituye una emergencia quirúrgica, por lo que los tiempos de preparación y los recursos difieren de una situación prevista. El problema anestésico no es la imposibilidad para la intubación traqueal, sino la dificultad para la ventilación con mascarilla facial o dispositivos supraglóticos, que cuando se ve comprometida supone un peligro para la vida del paciente(AU)

OBJETIVES: To determine the frequencies of variables that might predispose to upper airway collapse in a series of patients undergoing anterior cervical spine surgery. PATIENTS AND METHODS: Retrospective review of the medical records of 204 patients who underwent anterior cervical spine neurosurgery between 2003 and 2009. We gathered information on perioperative variables that might be related to upper airway collapse, on whether intensive care unit admission was planned or not, and on the moment when obstruction developed. RESULTS: Partial obstruction occurred in 7 cases (3.4%); 4 (1.9%) resolved with tracheal intubation and 3 (1.5%) required emergency tracheostomy. None of the variables were significantly associated with the development of postoperative upper airway obstruction in these patients. CONCLUSIONS: Upper airway obstruction after anterior cervical spine surgery is an unforeseen event and the emergency assessment of the airway may not coincide with the assessment of the anesthetist during the preanesthetic visit. This event may constitute an emergency for which preparation times and resources may differ from those available when this complication is foreseen. The problem for the anesthetist is not the impossibility of tracheal intubation but rather the difficulty of ventilating through a facial mask or supraglottic device, possibly with lifethreatening consequences(AU)

The 2009 devaluation of radiosurgery and its impact on the neurosurgery-radiation oncology partnership.

Neurosurgeons, radiation oncologists, and, increasingly, other surgical specialists recognize that radiosurgery is an important tool for managing selected disorders throughout the body. The partnership between neurosurgeons and radiation oncologists has resulted in collaborative studies that have established the clinical benefits of radiosurgery. Today, however, a range of political and financial issues is straining this relationship and thereby undermining the practice of radiosurgery. Neurosurgeons and radiation oncologists recently restricted the definition of radiosurgery to include only cranial- and spine-focused radiation treatments. Meanwhile, organized radiation oncology decided unilaterally that radiosurgery administered to other parts of the body would be termed stereotactic body radiation therapy. Finally, neurosurgical and radiation oncology coding experts developed new Current Procedural Terminology codes for cranial vault and spine radiosurgery, which were approved for use by the Relative Value Scale Update Committee as of 2009. The authors suggest that the neurosurgery strategy-which included 1) reasserting that all of the tasks of a radiosurgery procedure remain bundled, and 2) agreeing to limit the definition of radiosurgery to cranial vault and spine-has failed neurosurgeons who perform radiosurgery, and it may jeopardize patient access to this procedure in the future. The authors propose that all of the involved medical specialties recognize that the application of image-guided, focused radiation therapy throughout the body requires a partnership between radiation and surgical disciplines. They also urge surgeons to reexamine their coding methods, and they maintain that Current Procedural Terminology codes should be consistent across all of the different specialties involved in these procedures. Finally, surgeons should consider appropriate training in medical physics and radiobiology to perform the tasks involved in these specific procedures; ultimately all parties should receive equivalent reimbursement for similar assigned tasks, whether performed individually or jointly.

Neurocirurgia funcional / Functional neurosurgery

É realizada exposição dos objetivos principais da neurocirurgia funcional. O campo de ação, limites e filosofia de trabalho desta nova especialidade são revistos à luz da neurofisiologia...

Valuing neurosurgery services: part I. The historical development and interrelationships of current procedural terminology and the medicare fee schedule.

Current Procedural Terminology (CPT) standardizes medical procedure coding for billing and reimbursement. Since adoption of CPT coding as the basis for the Medicare Fee Schedule (MFS) in 1992, CPT coding policies and policy changes have been influenced not only by medical necessity and customary practice, but also increasingly by Medicare payment policies. The MFS created regulatory price control in the United States medical market based on widespread adoption of modified MFS by private payers and benchmark MFS fees governed by federal budget limitations and set annually by government agency (Centers for Medicare and Medicaid Services).

Classifications in routine use: lessons from ICD-9 and ICPM in surgical practice.

OBJECTIVE: Classifications of diagnoses and procedures are very important for the economical as well as the quality assessment of surgical departments. They should reflect the morbidity of the patients treated and the work done. The authors investigated the fulfillment of these requirements by ICD-9 (International Classification of Diseases: 9th Revision) and OPS-301, a German adaptation of the ICPM (International Classification of Procedures in Medicine), in clinical practice. DESIGN: A retrospective study was conducted using the data warehouse of the Surgical Center II at the Medical Faculty in Essen, Germany. The sample included 28,293 operations from the departments of general surgery, neurosurgery, and trauma surgery. Distribution of cases per ICD-9 and OPS-301 codes, aggregation through the digits of the codes, and concordance between the classifications were used as measurements. Median and range were calculated as distribution parameters. The concentration of cases per code was graphed using Lorenz curves. The most frequent codes of diagnoses were compared with the most frequent codes of surgical procedures concerning their medical information. RESULTS: The total number of codes used from ICD-9 and OPS-301 went up to 14 percent, depending on the surgical field. The median number of cases per code was between 2 and 4. The concentration of codes was enormous: 10 percent of the codes were used for about 70 percent of the surgical procedures. The distribution after an aggregation by digit was better with OPS-301 than with ICD-9. The views with OPS-301 and ICD-9 were quite different. CONCLUSION: Statistics based on ICD-9 or OPS-301 will not properly reflect the morbidity in different surgical departments. Neither classification adequately represents the work done by surgical staff. This is because of an uneven granularity in the classifications. The results demand a replacement of the ICD-9 by an improved terminological system in surgery. The OPS-301 should be maintained and can be used at least in the medium term.

Cuidados postoperatorios del paciente neuroquirúrgico crítico por patología vascular y tumoral cerebral / Care postoperatives the patients neurosurgical critical by patology vascular in brain

En el presente trabajo se reportan 66 pacientes neuroquirúrgicos que fueron admitidos a la Unidad de Cuidados Intensivos del Instituto Médico La Floresta durante el período postoperatorio de craneotomía debido a enfermedad tumoral (45 pacientes) y hemorragía subaracnoidea (HSA) debido a ruptura de aneurismas (28 pacientes ). La mortalidad perioperatoria global fue de 10.6 por ciento (7/66), siendo en el grupo neurooncológico (GNO) de 8.8 por ciento (4/45) y de 14,28 por ciento (3/21) en el grupo vascular (GV). El momento óptimo de la cirugía de aneurismas cerebrales así como el pronóstico en ambas series se puede anticipar mediante la escala de Hunt y Hess en el GV y el Apache II en ambas series respectivamente. El tratamiento adecuado de la HSA requiere un diagnóstico rápido y manejo agudo en la UCI, urgente evaluación neuroquirúrgica, manejo anestésico adecuado y cuidados críticos agresivos

Tumores intracraneales en el Hospital Nacional del sur IPSS / Intracraneal tumors in the Hospital Nacional del Sur-IPSS

En el presente trabajo se investigó la incidencia como manejo y evolución de pacientes con tumor intracraneal. El diagnóstico se confirmó con estudio histopatológico y los resultados obtenidos se evaluaron con el Rating de Karnofsky. De 1556 pacientes operados se encontró 54 casos (3.47 por ciento) de tumores intracraneales de los que 33.34 por ciento correspondian a gliomas, 31.48 por ciento a adenomas, 24.08 por ciento a meningiomas, papilomas de plexos coroideos y craneofaringiomas con 3.70 por ciento cada uno, finalmente el neurinoma del acústico y carcinoma de plexos coroideos con 1.85 por ciento. El sexo más afectado fue el masculino 74.07 por ciento y la edad más comprometida fue la quinta década de la vida (20.37 por ciento). Todos los pacientes recibieron tratamiento quirúrgico; 45 con cirugía total, 7 con parcial, 1 con descomprensiva y 1 con cirugía derivativa. En el post operatorio inmediato 50.02 por ciento tuvieron 80 a 90 en el Rating de Karnofsky y 18.50 por ciento estuvieron por debajo de 70. El resultado final arrojó 42.59 por ciento de pacientes aliviados, 38.86 por ciento de sanos y una mortalidad de 18.52 por ciento. Los resultados de este trabajo fueron comparados con otras casuísticas nacionales y extranjeras.

Classification and coding in neurosurgery.

Twelve years' experience in classification and coding by a neurosurgical department serving a population of about 1.5 million is presented. The involvement of clinicians and the relationship to health service resource management is demonstrated. The incorporation of a comprehensive coding system (the READ codes) is outlined.