Neurosurgical Service Research Articles

Neurosurgery residency program in Yogyakarta, Indonesia: improving neurosurgical care distribution to reduce inequality.

Educating future neurosurgeons is of paramount importance, and there are many aspects that must be addressed within the process. One of the essential issues is the disproportion in neurosurgical care, especially in low- and middle-income countries (LMICs). As stated in their report "Global Surgery 2030," The Lancet Commission on Global Surgery has emphasized that the availability of adequate neurosurgical care does not match the burden of neurosurgical disease. A strong partnership with the local and national government is very desirable to improve the way everyone addresses this issue. In addition, international collaborative effort is absolutely essential for the transfer of knowledge and technology from a developed country to an LMIC. This paper shows what the authors have done in Yogyakarta to build an educational model that helps to improve neurosurgical care distribution in Indonesia and reduce the inequity between provinces. The authors gathered data about the number of neurosurgical procedures that were performed in the sister hospital by using data collected by their residents. Information about the distribution of neurosurgeons in Indonesia was adapted from the Indonesian Society of Neurological Surgeons. The data show that there remains a huge disparity in terms of distribution of neurosurgeons in Indonesia. To tackle the issue, the authors have been able to develop a model of collaboration that can be applied not only to the educational purpose but also for establishing neurosurgical services throughout Indonesia. Currently they have signed a memorandum of understanding with four sister hospitals, while an agreement with one sister hospital has come to an end. There were more than 400 neurosurgical procedures, ranging from infection to trauma, treated by the authors' team posted outside of Yogyakarta. Indonesia has a high level of inequality in neurological surgery care. This model of collaboration, which focuses on the development of healthcare providers, universities, and related stakeholders, might be essential in reducing such a disparity. By using this model, the authors hope they can be involved in achieving the vision of The Lancet Commission on Global Surgery, which is "universal access to safe, affordable surgical and anesthesia care when needed."

The Predictive Value of the HOSPITAL Score and LACE Index for an Adult Neurosurgical Population: A Prospective Analysis

The HOSPITAL score (HS) and LACE index (LI) are 2 validated methods for quantifying the risk of 30-day unplanned readmission after discharge. However, neither score has been validated in the neurosurgical population. This study evaluated the HS and LI in the neurosurgical population as effective predictors for 30-day unplanned readmission. We performed a prospective, cohort analysis of all consecutive adult patients admitted to the neurosurgical service between October 1, 2018 and May 1, 2019. Patient medical records were used to calculate HS and LI. HS defined groups as low risk (0-4), intermediate (5-6), and high (7-12); LI defined risk as low (1-4), moderate (5-9), and high (10-19). Data analysis used univariate and multivariate logistic regressions. The 1242 patients included 626 women (50.4%). The average age was 57.9 years, and most patients (86.5%) underwent surgery during their admission. In multivariate logistic regression, intermediate-risk HS was not predictive of 30-day readmission (odds ratio [OR], 1.04; 95% confidence interval [CI], 0.57-1.88; P= 0.53), whereas high-risk HS did predict readmission (OR, 2.87; 95% CI, 1.49-5.54; P= 0.002). Likewise, moderate-risk LI was not predictive of 30-day unplanned readmission or mortality (OR, 1.59; 95% CI, 0.88-2.85; P= 0.12); however, high-risk LI did predict unplanned readmission or mortality (OR, 2.58; 95% CI, 1.16-5.73; P= 0.02). Both HS and LI showed poor to moderate discrimination (C= 0.62 and 0.60, respectively). A high-risk HS and high-risk LI were predictive of 30-day unplanned readmission. Although neither score is ideal for predicting moderate risk for 30-day unplanned readmission in neurosurgical patients, both have some predictiveness that may be clinically valuable.

The College of Surgeons of East, Central, and Southern Africa: Successes and Challenges in Standardizing Neurosurgical Training

The College of Surgeons of East, Central, and Southern Africa (COSECSA) is a regional accrediting body for general and specialty surgical training programs that has recently expanded to include neurosurgery. As neurosurgical services expand in sub-Saharan Africa, the structure of training and accreditation has become a vital issue. We review the founding and current structures of COSECSA neurosurgical training, identifying accomplishments and challenges facing the expansion of neurosurgical training in this region. The COSECSA model has succeeded in several countries to graduate qualified neurosurgeons, but challenges remain. Programs must balance the long duration of training required to promote surgical excellence against an overwhelming clinical need that seeks immediate solutions. Harnessing global collaboration, rapidly expanding local infrastructure, and a robust multinational training curriculum, COSECSA has emerged as a leader in the effort to train neurosurgeons and is anticipated to dramatically improve on the markedly unmet need for neurosurgical care in sub-Saharan Africa.

Education-based Solutions to the Global Burden of Neurosurgical Disease

Low- and middle-income countries continue to suffer from a lack of access to basic neurosurgical care. The 2015 Lancet Commission on Global Surgery estimated essential surgical care was lacking to 5 billion people and that 143 million essential surgeries were not performed annually. A significant part of this need is neurosurgical care. Countries lacking basic neurosurgical services cannot have a true trauma system, or complete care for tumor, stroke, pain, and congenital defects in children. Episodic service missions from developed countries cannot fill these large gaps. To maximize the impact of global neurosurgery, the framework through which humanitarian neurosurgeons respond to international need should incorporate sustainable practices that empower the recipient population. A historical and anecdotal review of global neurosurgery. The success of sustainable, locally championed neurosurgery educational programs will be dependent on the simultaneous, parallel development of anesthesia, critical care, nursing, and biomedical services. Each of these disciplines will reciprocally benefit from these neurosurgical programs. These programs cannot exist in a vacuum. They will require the thoughtful collaboration of all major neurosurgical societies with a humanitarian emphasis while championing the local surgeons in the area of need who must assume leadership to achieve a self-sustaining program. To meet the global need for neurosurgical care, self-sustaining neurosurgical programs must be locally developed in the countries of need. International support must be built on "Service through Education" rather the service alone.

Timing and dose of pharmacological thromboprophylaxis in adult trauma patients: Perceptions, barriers, and experience of Saudi Arabia practicing physicians

Background: Pharmacological venous thromboembolism prophylaxis (PVTE-Px) in trauma care is challenging and frequently delayed until the postinjury bleeding risk is perceived to be sufficiently low; yet, data for optimal initiation time are lacking. This study assessed the practice pattern of PVTE-Px initiation time and dose in traumatic brain injury (TBI), spinal cord injury (SCI), and nonoperative (NOR) solid organ injuries. Methods: This was a multicenter, cross-sectional, observational, survey-based study involving intensivists, trauma surgeons, general surgeons, spine orthopedics, and neurosurgeons practicing in trauma centers. The data of demographics, PVTE-Px timing and dose, and five clinical case scenarios were obtained. Analyses were stratified by early initiators versus late initiators and logistic regression models were used to identify factors associated with earlya initiation of PVTE-Px. Results: Of 102 physicians (29% response rate), most respondents were intensivists (63.7%) and surgeons (who are general and trauma surgeons) (22.5%); majority were consultants (58%), practicing at level 1 trauma centers (40.6%) or academic teaching hospitals (45.1%). A third of respondents (34.2%) indicated that decision to initiate PVTE-Px in TBI and SCI was made by a consensus between surgical, critical care, and neurosurgical services. For patients with NOR solid organ injuries, 34.2% of respondents indicated trauma surgeons initiated the decision on PVTE-Px timing. About 53.7% of the respondents considered their PVTE-Px practice as appropriate, half used combined mechanical and PVTE-Px (57.1%), 52% preferred enoxaparin (40 mg once daily), and only 6.5% used anti-Xa level to guide enoxaparin prophylactic dose. Responses to clinical cases varied. For TBI and TBI with intracranial pressure monitor, 40.3% and 45.6% of the respondents were early initiators with stable repeated head computed tomography (CT), respectively. For SCI, most respondents were early initiators without repeated CT spine (36.8%). With regard to NOR solid organ injuries (gunshot wound to the liver and Grade IV splenic injuries), 49.1% and 36.4% of respondents were early initiators without a repeat CT abdomen. Conclusions: Variations were observed in PVTE-Px initiation time influenced by trauma type. Our findings suggested that enoxaparin is preferred in a standard prophylactic dose. More robust data from randomized trials are needed and the use of clinicians' judgment is recommended.

Neurosurgery and Coronavirus: Impact and Challenges. Lessons Learnt from the First Wave of a Global Pandemic

Background: The novel severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has had a drastic effect on global healthcare with the UK amongst the countries most severely impacted. The aim of this study was to examine how COVID-19 challenged the neurosurgical delivery of care in a busy tertiary unit serving a socio-economically diverse population. We also describe the strategies we adopted to meet these challenges. Methods: A prospective single centre cohort study including all patients referred to the acute neurosurgical service or the subspecialty multi-disciplinary teams (MDT) as well as all emergency and elective admissions during COVID-19 (18th March 2020-15th May 2020) compared to pre-COVID-19 (18th of January 2020-17th March 2020). Data on demographics, diagnosis, operation, and treatment recommendation/outcome were collected and analysed. Findings: Overall, there was a reduction in neurosurgical emergency referrals by 33·6% and operations by 55·6% during the course of COVID-19. There was a significant increase in the proportion of emergency operations performed during COVID-19 (75·2% of total, n=155) when compared to pre-COVID-19 (n=198, 43·7% of total, pInterpretation: Despite the challenges, the capacity to safely treat patients requiring urgent or emergency neurosurgical care was maintained at all times. Strategies adopted to enable this included proactively approaching the referrers to maintain lines of communications, incorporating modern technology including telemedicine to run clinics and MDTs, restructuring patient pathways/facilities into COVID-19 positive and non-COVID-19, re-organising the staff rotas, and initiating the delivery of NHS care within private sector hospitals to increase operative capacity. We believe lessons learned here will have direct relevance for neurosurgical care during the current and future pandemics. Funding: Nil.Declaration of Interest: None of the authors have any conflict of interest or financial disclosure.Ethics Approval Statement: Local ethical approval was obtained.

The rise of quality indicators in neurosurgery: 30-day unplanned reoperation rate evaluated in 3760 patients-a single-center experience.

Quality indicators are emerging as tools to evaluate health care outcomes. Few studies have evaluated indicators suitable for neurosurgery so far. Among others, reoperation rate has been suggested as a possible indicator. We aimed to evaluate the reoperation rate in a large neurosurgery adult collective. In this exploratory post hoc analysis, we evaluated all patients operated in our service for elective and emergency surgery between January 2014 and May 2016. Planned and unplanned reoperations were filtered and a quantitative analysis, including uni- and multivariate analyses, was performed. A total of 3760 patients were included in this evaluation. From 378 reoperated patients within 30 days (10.1%), 51 underwent planned procedures (1.4%). Three hundred twenty-seven patients (8.7%) represented the analyzed collective of patients having undergone unplanned surgical procedures, causing a total of 409 from 4268 additional procedures (9.6%). Early unplanned 7-day reoperation rate was 4.5% (n = 193), occurring in 4.5% of patients (n = 193). Postoperative hemorrhage (n = 107, 26.2%) and external ventricle drainage-associated infections or dislocation (n = 105, 25.7 %) were the most common indication for unplanned surgery. Unplanned re-operation rate of a neurosurgical service can help to internally evaluate health care outcome and improve quality of care. Benchmarking with this indicator however is not recommendable as results can vary distinctly due to the heterogenic patient collective of each institution. We expect unplanned reoperation rates to be higher in large university hospitals and tertiary centers with complex cases, as compared to center with less complex cases treating patients with lower morbidity. In this study, we deliver an authentic portrait of a large neurosurgical center in Germany.

208.1: Use of collaborative request model was highly correlated with organ donation consent.

Background: There continues to be a disconnect between Australian’s self-reported support for organ donation and formal end-of-life family consent rates. In 2015, a multi-site Australian study by Lewis et al. demonstrated that consent rates were optimised by involving a clinician who had specific training in donation conversations, and in addition, was independent of the treating team. This approach is known as “Collaborative requesting” in Australia. The aim of the study was to report our single institution’s experience in introducing and augmenting the collaborative request model. Methods: The Royal Melbourne Hospital (RMH), is one of two adult tertiary trauma centres for the city of Melbourne, Australia. Additionally, the hospital has specialist neurosurgical and stroke services. Australia permits organ donation via both brain death and controlled circulatory death pathways. The hospital co-employs 4 embedded Donation Specialist Nursing Coordinators, and 3 fractionally appointed Medical Donation Specialists. Both craft groups have specialist communication training, and in addition, nursing coordinators have detailed end-to-end case donation management experience. Over a three-year period, the RMH progressively implemented the request model. Rather than using “any” independent clinician with donation communication training (the Lewis Model), the unit promoted the use of embedded Donation Specialist Nursing Coordinators as the collaborative requestors (the augmented collaborative model). Results: From January 2016 to June 2018 there were 135 donation requests raised by staff. Donation conversations raised by the family were excluded from analysis, as they have a consent rate at our hospital of over 90%. During the study period collaborative requesting increased from 50% (Jan 2016) to 96% (Jun 2018). Over the 3 study years (2016, 2017 and first half of 2018), the consent rate was highly positively correlated with the increased use of a collaborative model (r2=0.984). Conclusions: Since the introduction of embedded donation specialist nursing coordinators in RMH ICU, the hospital has seen both a clinically and statistically significant improvement in organ donation consent rates. These improvements in consent rates have been demonstrated to be highly correlated with the implementation of an augmented collaborative model within our unit. The dose-response relationship provides weight to a causational link.The excess consent rate observed in our unit in comparison to the multi-site Lewis et al study may be due to the concentration of performance of a clinical skill into a small number of requestors, and excellent end-to-end process knowledge. Further study is recommended. Conclusions: Collaborative requesting for permission to proceed with organ donation was highly correlated with improved consent rates, in this centre with the predominant use of Specialist Nursing Coordinator collaborators.

Clinical and morphological profile of aneurysms of the anterior communicating artery treated at a neurosurgical service in Southern Brazil.

Background:The aim of the study was to characterize the clinical profile of patients with anterior communicating artery (ACoA) aneurysms and examine potential correlations between clinical findings, aneurysm morphology, and outcome.Methods:A review of medical records and diagnostic neuroimaging reports of patients treated at a neurosurgical service in Porto Alegre, Brazil, between August 2008 and January 2015 was performed.Results:During the period, 100 patients underwent surgery for ACoA aneurysms. Fifteen had unruptured aneurysms and 85 had ruptured aneurysms. Ruptured aneurysms had a higher aspect ratio than unruptured ones (2.37 ± 0.71 vs. 1.93 ± 0.51, P = 0.02). Intraoperative rupture occurred in 3%, and temporary clipping was performed in 15%. Clinical vasospasm occurred in 43 patients with ruptured aneurysms (50.6%). Overall, mortality was 26%; 25 patients in the ruptured group (29.4%) and one in the unruptured group (6%). The Glasgow Outcome Scale (GOS) was favorable (GOS 4 or 5) in 54% of patients, significantly more so in those with unruptured aneurysms (P = 0.01). In patients with ruptured aneurysms, mortality was associated with preoperative Hunt and Hess (HH) score (P < 0.001), hydrocephalus (P < 0.001), and clinical complications (P < 0.001). Unfavorable outcomes were associated with HH score (P < 0.001), Fisher grade (P = 0.015), clinical vasospasm (P = 0.012), external ventricular drain (P = 0.015), hydrocephalus (P < 0.001), and presence of clinical complications (P = 0.001). In patients with unruptured aneurysms, presence of clinical complications was the only factor associated with mortality (P < 0.001).Conclusion:Despite advances in the management of subarachnoid hemorrhage and surgical treatment of aneurysms, mortality is still high, especially due to clinical complications.

Gracias Instituto Asenjo

El objeto de este artículo es que agradecer a la Sociedad Neurológica de Chile la influencia que ha tenido en Antioquia y Colombiaformando nuestros lideres en neurocirugía, especialmente por haber formado al Doctor Ernesto Bustamante, fundador del Servicio de Neurocirugía de la Universidad de Antioquia que cumple 65 años de existencia. Sin embargo, este no fue el único Neurocirujano de Colombia que recibió su entrenamiento en Chile, también lo fueron los Doctores Ernesto Arango Tamayo, Alejandro Jiménez Arango, Raúl Piedrahita, Carlos Pardo, Bernardo Soto, Hans Carmona, Alveiro Morales y muchos otros cuyo nombre desconozco. Sea esta la oportunidad para retomar y fortalecer los lazos académicos entre nuestras sociedades científicas. Gracias Instituto Asenjo

05 Profile of a Geriatric Neurosurgical Service

Abstract Background According to the 2016 CSO figures the age category of 65 and older saw the largest increase in the Irish population since 2011, rising by 102,174 to 637,567, a rise of 19.1%. This remains a major concern for a North Dublin teaching hospital as its catchment area has a 20% higher proportion of &gt; 65’s and &gt; 85’s than the national average. This catchment area profile has the potential to impact on the profile of the in-catchment admissions while the National profile will impact on the national specialities including neurosurgery. Aim To profile the geriatric neurosurgical population and provide insight that facilitates future service planning and delivery. Methods To accurately capture the data, all ward lists for the month of June and July 2017 were reviewed to identify appropriate patients. All patients on any ward within the hospital, under the care of a neurosurgeon, were included in the data collection. Patients in intensive care that did not transfer to the wards were excluded. Data points including age, sex, consultant, co-morbidities, mobility status and surgical intervention were captured. Results 120 patients ≥ 65 years were admitted to the neurosurgical service between June and July 2017; 45 (38%) between 60-69, 60 (50%) 70-79, 13(10%) 80-80 and two (2%) ninety years or older. The two most common reasons for admission were non-traumatic cerebral bleeds (N= 40; 34%) and cerebral tumours (N= 38; 32%). Patients had on average four co-morbidities, with cardiac being the most common. 17 patients were admitted post a traumatic event; 13 low impact falls, 3 high impact falls and one assault. The average LOS for these patients was 11.3 days. Conclusion This profile highlights the complex needs of this population and the increasing burden on existing neurosurgical resources as the population continues to age. Future resource allocation and service development, including the National Trauma Strategy, needs to consider the needs of the aging neurosurgical population.

Microdiscectomía lumbar ambulatoria en el hospital de Puerto Montt: segura, alta satifacción usuaria y menor costo

Desde julio de 2007 el tratamiento quirúrgico de radiculopatías por hernia del núcleo pulposo (HNP) lumbares formó parte del sistema de garantías explícitas de salud (GES). Objetivo: Comparar de forma retrospectiva los resultados de dos cohortes de pacientes con indicación de cirugía discal lumbar seleccionados por el protocolo del Hospital de Puerto Montt para microdiscectomía lumbar ambulatoria (MLA). Métodos: Se incluyeron todos los pacientes seleccionados por el protocolo, que se operaron de microdiscectomía lumbar (ML) entre julio de 2015 hasta febrero de 2017. Se comparó de forma retrospectiva la homogeneidad de la cohorte de pacientes ambulatorios con la de hospitalizados. Se analizó: alivio del dolor, complicaciones, días camas, tiempo de espera a la cirugía, costos y satisfacción usuaria. Resultados: 253 pacientes operados de ML desde el inicio del protocolo hasta febrero de 2017, 126 fueron seleccionados para MLA por el protocolo, de estos 41 fueron efectivamente ambulatorios y 85 requirieron hospitalización, generándose dos cohortes homogéneas. La tasa total de complicaciones para ambos grupos fue de 4,9% y 16% respectivamente, no hubo complicaciones mayores. En los pacientes ambulatorios se ahorraron $3.145.110 pesos chilenos y se liberaron 82 días camas. El tiempo de espera para ser operados fue significativamente menor en el grupo ambulatorio. La satisfacción usuaria fue similar en ambos grupos. Conclusiones: El realizar MLAha sido seguro para nuestros pacientes sin mayores complicaciones o cambios en la satisfacción usuaria. El protocolo ha disminuido el número de días cama, los costos y el tiempo de espera para acceder a la cirugía.

Overview of neurosurgical capacity in St. Lucia

When we talk about the most scenic Caribbean islands, St. Lucia is one of those islands that certainly come into our mind. It is a beautiful tourist destination and the place of post-volcanic paradise on earth. However, just like many remote Caribbean islands, St. Lucians (name for local population) used to have its own difficulties of obtaining on demand basic neurosurgical services in their homeland. This beautiful Caribbean island, socioeconomically falls in the same category as most low-and middle-income countries (LMICs) and unfortunately echoes the same unmet surgical and anaesthesia needs as the rest of them.

Causes of Hospital Readmissions Within 7 Days From the Neurosurgical Service of a Quaternary Referral Hospital

Abstract INTRODUCTION Unplanned hospital readmission after discharge is an important quality metric. Such readmissions are associated with greater healthcare costs, decreased patient satisfaction, decreased clinical outcomes, and sometimes financial penalties. A large amount of data has been documented regarding 30-d readmissions for neurosurgical populations. However, a focus on 7-d readmissions may provide an insight into the causes of unplanned readmissions, perhaps translate into decreases in 30-d readmissions. This study was performed in order to determine the causes of 7-d readmissions and to define risk factors that, if addressed, would allow for a reduction of such readmissions. METHODS All patients readmitted after discharge within 7 d from the neurosurgical service from the University of Pittsburgh Medical Center, Presbyterian Hospital, during 2018 were evaluated. There were 18 different providers. Demographic data were collected for all patients. The primary reason for readmission was organized using a 5-category system: surgical site infection, pain, altered mental status/seizures, other postoperative complications [eg, venous thromboembolism (VTE), urinary tract infection, pneumonia, CSF leak, hematoma, shunt failure] and “unrelated.” RESULTS Of 5184 discharges, 169 patients (3.3%) were readmitted within 7 d (55% men; mean age 62 yr). A total of 65% had undergone care for cranial pathology and 35% for spine (versus 55% and 45%, respectively, in the total discharge population). Other postoperative complications were the leading cause of readmission (40%), followed by altered mental status/seizure and unrelated (20% each). Surgical site infection and postoperative pain exhibited the lowest rates of 10% each. CONCLUSION The overall 7-d readmission rate was 3.3%. There was nearly a 2:1 ratio for cranial versus spinal patients for 7-d readmissions. The majority of readmissions were related to postoperative complications, whether directly related to surgical intervention or perioperative complications. Focal efforts to decrease specific postoperative complications should translate into a reduction in both 7- and 30-d unplanned readmissions.

Implementation of simulation modelling to improve service planning in specialist orthopaedic and neurosurgical outpatient services

BackgroundAdvanced physiotherapist-led services have been embedded in specialist orthopaedic and neurosurgical outpatient departments across Queensland, Australia, to ameliorate capacity constraints. Simulation modelling has been used to inform the optimal scale and professional mix of services required to match patient demand. The context and the value of simulation modelling in service planning remain unclear. We aimed to examine the adoption, context and costs of using simulation modelling recommendations to inform service planning.MethodsUsing an implementation science approach, we undertook a prospective, qualitative evaluation to assess the use of discrete event simulation modelling recommendations for service re-design and to explore stakeholder perspectives about the role of simulation modelling in service planning. Five orthopaedic and neurosurgical services in Queensland, Australia, were selected to maximise variation in implementation effectiveness. We used the consolidated framework for implementation research (CFIR) to guide the facilitation and analysis of the stakeholder focus group discussions. We conducted a prospective costing analysis in each service to estimate the costs associated with using simulation modelling to inform service planning.ResultsFour of the five services demonstrated adoption by inclusion of modelling recommendations into proposals for service re-design. Four CFIR constructs distinguished and two CFIR constructs did not distinguish between high versus mixed implementation effectiveness. We identified additional constructs that did not map onto CFIR. The mean cost of implementation was AU$34,553 per site (standard deviation = AU$737).ConclusionsTo our knowledge, this is the first time the context of implementing simulation modelling recommendations in a health care setting, using a validated framework, has been examined. Our findings may provide valuable insights to increase the uptake of healthcare modelling recommendations in service planning.

Economic benefit of neurosurgical intervention for infant hydrocephalus in Haiti.

Previous models have been utilized in other low- and middle-income countries (LMICs) to explore and assess the cost, sustainability, and effectiveness of infant hydrocephalus treatment. However, similar models have not been implemented in Haiti due to a paucity of data, epidemiology, and outcomes for hydrocephalus. Therefore, the authors utilized previously described economic modeling to estimate the annual cost and benefit of treating hydrocephalus in infants at a neurosurgery referral center, Hospital Bernard Mevs (HBM), in Port-au-Prince, Haiti. The authors conducted a retrospective review of data obtained in all children treated for hydrocephalus at the HBM from 2008 to 2015. The raw data were pooled with previously described surgical outcomes for hydrocephalus in other LMICs. Modeling was performed to determine outcomes, neurosurgical costs, disability-adjusted life years (DALYs), and economic benefits of Haitian hydrocephalus treatment during this time frame. Standard account methodology was employed to calculate cost per procedure. Using these formulas, the net economic benefit and cost/DALY were determined for hydrocephalus treatment at HBM from 2008 to 2015. Of the 401 patients treated during the study period, 158 (39.4%) met criteria for postinfectious hydrocephalus, 54 (13.5%) had congenital hydrocephalus, 38 (9.5%) had myelomeningocele, 19 (4.7%) had aqueductal stenosis, and 132 (33%) were not placed into a category. Overall, 317 individuals underwent surgical treatment of their hydrocephalus, averting 3077 DALYs. The total cost of the procedures was $754,000, and the cost per DALY ranged between $86 and $245. The resulting net economic benefit for neurosurgical intervention ranged from $2.5 to $5.5 million. This work demonstrates the substantial economic benefit of neurosurgical intervention for the treatment of pediatric hydrocephalus at a single hospital in Haiti. Based on DALYs averted, the need for additional centers offering basic neurosurgical services is apparent. A single center offering these services for several days each month was able to generate between $2.5 to $5.5 million in economic benefits, suggesting the need to develop neurosurgical capacity building in Haiti. Ultimately, prevention, screening, and early surgical treatment of these infants represent a public health and socioeconomic requisite for Haiti.

In Reply: Institutional Review of Mortality in 5434 Consecutive Neurosurgery Patients: Are We Improving?

BACKGROUND Despite increasing emphasis on quality improvement in neurosurgery, few studies have evaluated the impact of quality initiatives on health-assessment metrics including risk of mortality (ROM), severity of illness (SOI), case mix index (CMI), and mortality index. OBJECTIVE To evaluate the impact of a multifactorial quality initiative on mortality and quality metrics on a neurosurgical service. METHODS Records of 5434 consecutive neurosurgery inpatients and consults including all inpatient mortalities were prospectively collected and reviewed from July 2014 to June 2016 at major academic institution. A multifactorial quality improvement intervention was implemented in July 2015. UHC risk models mortality index, CMI, ROM, SOI present on admission (POA), and at hospital discharge (DC) were compared in the prior 12 mo and the 12 m after implementation. For mortality cases, diagnosis-related group codes, procedure type, and etiology of mortality were collected. RESULTS Compared to the pre-intervention cohort (n = 2793), the postintervention cohort (n = 2641) trended to have a decreased mean-observed monthly mortality (3.08 vs 4.17) and mean-monthly mortality index (0.73 vs 0.98). Additionally, the postintervention cohort had significantly higher CMI (3.14 vs 2.96, P = .02), POA-ROM (1.52 vs 1.46, P = .02), POA-SOI (1.97 vs 1.84, P = .0002), DC-ROM (1.69 vs 1.58, P = .003), and DC-SOI (2.1 vs 1.95, P < .0001). Of 131 mortalities (pre-intervention: n = 70, postintervention: n = 61), the postintervention cohort had a higher proportion of moralities due to emergent and trauma admissions than elective. CONCLUSION Our study suggests that our quality initiative impacted observed mortality, improved documentation, and enhanced overall quality of care on a neurosurgical service.

Length of Stay Beyond Medical Readiness in Neurosurgical Patients: A Prospective Analysis.

In an era of growing healthcare costs, there is increased pressure on medical care providers to discharge patients once they are medically fit. However, it is not uncommon for patients to stay beyond medical readiness (BMR). To analyze the frequency with which patients remain in the hospital BMR. A prospective cohort analysis utilizing a database maintained between 2014 and 2015 included 718 adults admitted to the neurosurgical service. The attending for admitted patients was asked on a daily basis as to whether the patient was medically cleared for discharge. Standard statistical analyses were performed. Of the 718 patients, 105 (14.6%) remained in the hospital BMR. Of the patients who presented with a spinal pathology, 17.8% had a length of stay (LOS)-BMR compared to 13.9% who presented with cerebrovascular pathologies and 14.8% who presented with a brain tumor. The average LOS-BMR was 1.8 d. Only 7.7% of patients who were discharged home had an LOS-BMR compared to 30.7% of patients who were discharged to a skilled nursing facility or rehabilitation center (P<.001). In logistic regression, a physical therapy consultation and discharge to a specialized nursing facility were both associated with a longer LOS (average 2.4 d longer, P<.001, and 6.2 d longer, P=.028, respectively). However, neither was associated with an LOS-BMR. LOS-BMR is an important process engineering concept within neurosurgery that represents a potential area for improvement to maximize limited healthcare resources. A sizeable portion of neurosurgical patients remained in the hospital BMR.

Comparing the outcomes of isolated, serious traumatic brain injury in older adults managed at major trauma centres and neurosurgical services: A registry-based cohort study

BackgroundThe incidence of older adult traumatic brain injury (TBI) is increasing in both high and middle to low-income countries. It is unknown whether older adults with isolated, serious TBI can be safely managed outside of major trauma centres. This registry based cohort study aimed to compare mortality and functional outcomes of older adults with isolated, serious TBI who were managed at specialised Major Trauma Services (MTS) and Metropolitan Neurosurgical Services (MNS). MethodOlder adults (65 years and over) who sustained an isolated, serious TBI following a low fall (from standing or ≤ 1 m) were extracted from the Victorian State Trauma Registry from 2007 to 2016. Multivariable models were fitted to assess the association between hospital designation (MTS vs. MNS) and the two outcomes of interest: in-hospital mortality and functional outcome, adjusting for potential confounders. Functional outcomes were measured using the Glasgow Outcome Scale Extended at six months post-injury. ResultsFrom 2007–2016, there were 1904 older adults who sustained an isolated, serious TBI from a low fall who received definitive care at an MTS (n = 1124) or an MNS (n = 780). After adjusting for confounders, there was no mortality benefit for patients managed at an MTS over an MNS (OR = 0.84; 95% CI: 0.65, 1.08; P = 0.17) or improvement in functional outcome six months post-injury (OR = 1.13; 95% CI: 0.94, 1.36; P = 0.21). ConclusionFor older adults with isolated, serious TBI following a low fall, there was no difference in mortality or functional outcome based on definitive management at an MTS or an MNS. This confirms that MNS without the added designation of a major trauma centre are a suitable destination for the management of isolated, serious TBI in older adults.

SPONDYLODISCITIS INVESTIGATION AND THERAPEUTIC PROTOCOL: NEUROSURGERY SERVICE RESULTS

ABSTRACT Objective: Spondylodiscitis is still a frequent pathology among neurosurgical services, and its correct treatment involves infectious, neurological and orthopedic goals. The authors describe the protocol and report the diagnostic and therapeutic results after its implementation. Methods: A prospective prognostic study (Level I) including patients with primary spondylodiscitis treated in the Neurosurgical Service of Cristo Redentor Hospital from January 2014 to March 2018. Demographic, spine, infectious and treatment-related variables were analyzed. The numerical variables are presented as mean and standard deviation or median and interquartile range (according to their parametricity), and are compared by the student's t-Test or Mann-Whitney U Test, respectively. Results: Thirty seven patients were included. The sexes were evenly distributed, with predominantly Caucasians, and a mean age of 56.89 ±15.33. Hypertension and type 2 diabetes were the most frequent comorbidities. Vertebral lumbar level was the most involved segment. Pathogens were identified in 34 cases (91%), with Staphylococcus aureus being the most prevalent, followed by Koch Bacilli. Inflammatory markers are higher in pyogenic infections at hospital admission, but lower at hospital discharge when compared to tuberculous discitis (p&lt;0.01). Mean hospital stay was higher in the pyogenic group. Conclusion: The protocol described has a high diagnostic level of the pathogen, with cure of infection and satisfactory neurologic outcome in all cases. Level of Evidence I, Diagnostic Studies - Investigating a Diagnostic Test.