Tracheostomy placement in patients with complete cervical spinal cord injuries: American Spinal Injury Association Grade A.

OBJECT: The authors sought to identify variables that predispose patients with acute American Spinal Injury Association (ASIA) Grade A cervical spinal cord injury (SCI) to require tracheostomies for ventilator support or airway protection. METHODS: A retrospective analysis was performed of 178 consecutive patients with a cervical ASIA Grade A SCI who were admitted through the Delaware Valley SCI Center at Thomas Jefferson Hospital during a 6-year period. Exclusion criteria included injury occurring more than 48 hours prior to admission, death within 14 days of admission or nontraumatic SCI. Twenty-two patients were excluded based on these criteria. Parameters evaluated in the remaining population (156 patients) included demographics, cervical vertebral ASIA level, tracheostomy placement, pneumonia, premorbid pulmonary disease, smoking history, evidence of direct thoracic/lung trauma, operative intervention, associated appendicular trauma, and preexisting medical comorbidities. The ASIA classification of the 156 patients included in this analysis were C-2 (eight), C-3 (11), C-4 (64), C-5 (36), C-6 (20), C-7 (13), and C-8 (four). Tracheostomies were performed in 107 of these 156 patients. Statistical analysis revealed a significant relationship between tracheostomy and patient age (p = 0.0048), preexisting medical conditions (p = 0.0417), premorbid lung disease (p = 0.0177), higher cervical ASIA level (p < 0.0001), and the presence of pneumonia (p < 0.0001). No patient with a C-8 ASIA A injury required tracheostomy, whereas all C-2 and C-3 ASIA A-injured patients underwent tracheostomies. Patients older than 45 years of age with ASIA A levels between C-4 and C-7 more commonly required tracheostomy (p < 0.005) than patients younger than 45 years of age. CONCLUSIONS: Several risk factors were identified that corresponded to the frequent tracheostomy placement in the acute injury phase after complete cervical SCI. Early tracheostomy may be considered in patients with multiple risk factors to reduce duration of stay in the intensive care unit and facilitate ventilatory weaning.

Understanding and applying a resource-based relative value system to your neurosurgical practice.

The payment policy for United States physicians was formerly based on determination of customary and prevailing charges from their fee schedules. Rapidly growing health care expenditures in the 1980s led to a fundamental change in payment reimbursement in which the new system was based on the resource costs to the physician for providing health care services. This reform highlights the significant regulatory morass that has come to burden the health care industry. One of the most critical changes in physician reimbursement was caused by the Congressional mandate that led to the development of a resource-based relative value scale (RBRVS) for the creation of the Medicare physician fee schedule. Most physicians, however, have limited familiarity with the RBRVS system, which now serves as the basis for Medicare-related physician reimbursement as well as many third-party payers. A historical review of the development of the RBRVS will serve as the basis for applying the methodology to improve the effectiveness of the neurosurgeon's practice.