Subject: Socioeconomic
Title: Neurosurgery in Kenya
Authors: John B Dietze
Introduction: In August of 2015, I was afforded the opportunity to travel to Tenwek Mission Hospital in Bomet, Kenya. While there I performed 28 neurosurgical operations and consulted on nearly 200 outpatients in the neurosurgery clinic.
Methods: Tenwek is a 300 bed teaching hospital in Bomet which in southwestern Kenya. It provides primary healthcare for a population of 600,000 people within a 32 kilometer radius. It also serves as a specialty referral hospital for a much larger population. At present there is no full-time neurosurgeon.
Results: There are currently only 17 full time neurosurgeons in Kenya, 14 of which work out of only 2 tertiary care hospitals in Nairobi and Eldoret. The ratio for the country is 1 neurosurgeon per 2.5 million people. However, being more highly developed than neighboring countries, Kenyan neurosurgeons provide care for much of East Africa such that the ratio is actually 1 per 11 million. The 24 hour mortality rate for sever closed head injuries is greater than 50 percent.
Conclusions: In light of the extremely limited availability of neurosurgical care in Kenya and East Africa, there is almost no limit to how much impact someone who is willing to offer their skills can have on that part of the world. While the lack of resources is daunting and requires creativity to navigate, the rewards are impossible to overstate.
Keywords: Developing World, Limited Access
Objectives: To appreciate the need to bring neurosurgical care into developing nations. To gain insight into some of the challenges that face performing neurosurgery with extremely limited resources. To be gain perspective on some of the unique neurosurgical issues that are confronted in developing countries,
Subject: Cerebrovascular
Title: Retrospective Review of Flow Diverters in the Treatment of Intracranial Aneursym
Authors: Steven Sharp; Babu Welch; Jonathan A. White
Introduction: There have been inconsistent rates of complications reported with the use of flow diverter devices in the treatment of intracranial aneurysms. However, higher rates of complications have been associated with giant aneurysms, posterior circulations and lowest in the internal carotid aneurysms. We performed an analysis of our database of cases from the previous four years.
Methods: We performed a 4 year retrospective study at the University of Texas Southwestern Medical Center involving the treatment of intracranial aneurysms with flow diverter devices, specifically Pipeline or Surpass devices. Complications reported included hemorrhage, ischemic stroke and death.
Results: Seventy-three patients with intracranial aneurysms were treated with flow diverter devices, specifically Pipeline or Surpass. Overall complication was 13.7% with permanent complication rate of 8.2%. There was one mortality (1.4%) , two hemorrhages (2.7%) and seven ischemic strokes (9.6%) with details presented in the figures (fig. 1). Of the seven ischemic strokes, four ischemic strokes resulted in permanent deficits and of the three hemorrhages, one hemorrhage resulted in permanent deficit and one in mortality.
Conclusions: The complications of flow diverter in our series was found to be 13.7% overall with permanent complication rate of 8.2%. Flow diverters have been shown to be viable treatment options for intracranial aneurysms, with traditionally being used in wide neck or fusiform aneurysms but increasingly used in smaller aneurysms. The benefits of flow diverters outweigh the complications in the treatment of intracranial aneurysms.
Keywords: Flow diverter, intracranial aneurysm
Objectives: Understand basic complications.
Subject: Cerebrovascular
Title: Retrospective Review of Flow Diverters in the Treatment of Intracranial Aneursym
Authors: Steven Sharp; Babu Welch; Jonathan A. White
Introduction: There have been inconsistent rates of complications reported with the use of flow diverter devices in the treatment of intracranial aneurysms. However, higher rates of complications have been associated with giant aneurysms, posterior circulations and lowest in the internal carotid aneurysms. We performed an analysis of our database of cases from the previous four years.
Methods: We performed a 4 year retrospective study at the University of Texas Southwestern Medical Center involving the treatment of intracranial aneurysms with flow diverter devices, specifically Pipeline or Surpass devices. Complications reported included hemorrhage, ischemic stroke and death.
Results: Seventy-three patients with intracranial aneurysms were treated with flow diverter devices, specifically Pipeline or Surpass. Overall complication was 13.7% with permanent complication rate of 8.2%. There was one mortality (1.4%) , two hemorrhages (2.7%) and seven ischemic strokes (9.6%) with details presented in the figures (fig. 1). Of the seven ischemic strokes, four ischemic strokes resulted in permanent deficits and of the three hemorrhages, one hemorrhage resulted in permanent deficit and one in mortality.
Conclusions: The complications of flow diverter in our series was found to be 13.7% overall with permanent complication rate of 8.2%. Flow diverters have been shown to be viable treatment options for intracranial aneurysms, with traditionally being used in wide neck or fusiform aneurysms but increasingly used in smaller aneurysms. The benefits of flow diverters outweigh the complications in the treatment of intracranial aneurysms.
Keywords: Flow diverter, intracranial aneurysm
Objectives: Understand potential complications of flow diverters
Subject: Socioeconomic
Title: Call Sucks: building resilence in a changing value system for neurological surgery
Authors: Origitano TC
Introduction: Significant changes in healthcare economics (mergers, employment, ACOs) have created associated toxic triad of high demand, low support, and low control dynamics which are leading causes of burnout and maladaptive behaviors in surgeons.
Methods: These factors are best represented by neurosurgical call. At any stage in a neurosurgeons career call is one of the most significant stressors and dissatisfiers. It invades the surgeon’s home, psyche, and physical well being. Nationally, it is a sought after resource which often differentiates between healthcare systems
Results: The impact of call and the changing healthcare evaluation of neurological surgeons will be detailed. Potential mechanism for decreasing maladaptive behaviors and managing the stressors of call will be presented.
Conclusions: There are significant dynamics in healthcare today which are challenging the psyche and productivity of surgeons. The nature of neurological surgery exacerbates this stressors. Considerations for avoidance, interdiction and management of maladaptive behaviors will be presented.
Keywords: resilence, burnout, value, ca;;
Objectives: Recognition of dynamic stressors in neurological surgery practices and call Develop mechanism for interdiction, avoidance and management of maladaptive behaviors Develop mechanism to build resilience into your neurosurgical practice
Subject: Cerebrovascular
Title: A Case Series of Dural Venous Sinus Stenting in Idiopathic Intracranial Hypertension: Association of Outcomes with Optical Coherence Tomography
Authors: Kyle A Smith; Jeremy C Peterson; Michael G Abraham
Introduction: Pseudotumor cerebri, or idiopathic intracranial hypertension (IIH), is characterized by increased intracranial pressure of unknown etiology. A subset of patients has shown benefit from endovascular dural venous sinus stenting (DVSS). We sought to identify a population of IIH patients who underwent DVSS to assess outcomes.
Methods: A retrospective study was performed to identify IIH patients with dural sinus stenosis treated with DVSS. Outcome measures included dural sinus pressure gradients, peripapillary retinal nerve fiber layer thickness using optical coherence tomography, and improvement in symptoms.
Results: Seventeen patients underwent DVSS. Average pre- and post-intervention pressure gradients were 23.06 mmHg and 1.18 mmHg, respectively (p<0.0001). Sixteen (94%) noted improvement in headache, fourteen (82%) had visual improvement, and all (100%) patients had improved main symptom. Of 11 patients with optical coherence tomography, eight showed decreased RNFL thickness and three remained stable; furthermore, these eleven patients had improved vision with improved papilledema in eight, lack of per-existing papilledema in two, and stable, mild edema in one patient.
Conclusions: Our series of patients with dural sinus stenosis demonstrated improvement in vision and reduction in retinal nerve fiber layer thickness. DVSS appears to be a useful treatment for IIH patients with dural sinus stenosis.
Keywords: Pseudotumor, Venous stenosis, Stent
Objectives: 1. Understand pre-procedural patient indications/contraindications for dural venous sinus stenting. 2. Understand pre- and post-procedural care for dural venous sinus stenting in the IIH patient population. 3. Understand procedural technique for dural venous sinus stenting.
Subject: Spine
Title: Difficult cases in spine surgery
Authors: Dusty Richardson; Michael A Finn; Peter Witt
Introduction: This presentation focuses on educational aspects and review of pertinent literature surrounding difficult spine surgery cases including fracture, trans-foraminal lumbar interbody fusion, and chin-on-chest cervical deformity
Methods: Case reports are presented in an fashion that fosters audience involvement and opinion.
Results: Complications, subsequent surgery, and final results are presented.
Conclusions: Difficult spine cases represent an educational opportunity for all involved.
Keywords: TLIF, Spine, Fracture, Cervical
Objectives: Difficult spine cases will be presented with pertinent literature review and encouragement of audience participation
Subject: Trauma
Title: A Prospective Analysis of Hypovitaminosis D and Mortality in 400 Patients in the Neurocritical Care Setting
Authors: Jian Guan; Michael Karsy; Andrea Brock; Ilyas Eli; Holly Ledyard; Gregory W Hawryluk; Min S Park
Introduction: Hypovitaminosis D is highly prevalent among the general population. Studies have shown an association between hypovitaminosis D and multiple negative outcomes in critical care patients, but there has been no prospective evaluation of hypovitaminosis D in the neurological critical care population. The authors examined the impact of vitamin D deficiency on in-hospital mortality and a variety of secondary outcomes in the neurocritical care unit.
Methods: The authors prospectively collected 25-hydroxy vitamin D levels on all patients admitted to the neurocritical care unit of a quaternary-care center over a three-month period. Demographic data, illness acuity, in-hospital mortality, infection, and length of hospitalization were collected. Univariate and multivariable logistic regression were used to examine the effects of vitamin D deficiency.
Results: Four hundred sixty-one patients met the inclusion criteria. In-hospital mortality was slightly worse (9.3% vs. 4.5%, p=0.059) among patients with deficient vitamin D (<=20 ng/dL). There was also a higher rate of urinary tract infection in patients with vitamin D deficiency (12.4% vs. 4.2%, p=0.002). For patients admitted to the neurocritical care unit emergently (N=285), higher SAPS II score (OR 13.33, 95% CI 1.69–100, p=0.014) and vitamin D deficiency (OR 3.03, 95% CI 1.14–8.06, p=0.027) were significantly associated with increased in-hospital mortality on multivariable analysis.
Conclusions: In the subset of patients admitted to the neurocritical care unit emergently, vitamin D deficiency is significantly associated with higher in-hospital mortality. Larger studies are needed to confirm these findings and to investigate the role of vitamin D supplementation in these patients.
Keywords: Vitamin D, mortality, neurocritical care
Objectives: By the conclusion of this session, participants should be able to: 1) Describe the prevalence of hypovitaminosis D in the neurocritical care population. 2) Discuss, in small groups, the association of hypovitaminosis D and mortality in the neurocritical care unit. 3) Identify morbidity associated with hypovitaminosis D in the neurocritical care population.
Subject: Tumor
Title: Sacral Mass in a 66 year old male.
Authors: Joseph G Sramek
Introduction: 66 year old male presents with six month history of pain in the tailbone region.
Methods: MRI imaging reveals 4.9 x 5.3 x 4.9 cm lobulated mass arising from the S5 level with some extension along ventral aspect of S4. En bloc resection of mass with repair of defect with 2 layer mesh performed with assistance of surgical oncology.
Results: Surgical Pathology consistent with Sacral Chordoma. Patient clinically doing well with preserved bowel and bladder function and good wound healing.
Conclusions: Will discuss differential diagnosis, epidemiology, surgical anatomy and technique, Risks inherent to surgery in this area, role of adjuvant therapy and prognosis.
Keywords: Sacral, chordoma
Objectives: Understand differential diagnosis of sacral mass. Understand surgical approaches and regional anatomy. Understand role of adjuvant therapy.
Subject: Trauma
Title: VTE Chemoprophylaxis in Traumatic Intracranial Hemorrhage
Authors: Allison Whipple
Introduction: Venous thromboembolism (VTE) is a common and mostly preventable complication among neurosurgical patients. There is currently no recognized standard of care on this topic. Clinicians regularly face dilemmas about how best to treat their patients. The purpose of this project was to attempt to decrease clinician dilemma regarding when to initiate VTE chemoprophylaxis in patients with traumatic intracranial hemorrhage (intra-cerebral hemorrhage, traumatic subarachnoid hemorrhage, epidural hematoma, and subdural hematoma).
Methods: A literature review was conducted and an appropriate algorithm for VTE prophylaxis was identified. The project was conducted at a single level one-trauma center. Current standard practice was determined through a pre-implementation questionnaire that was administered to 7 Neurosurgical providers and 5 advanced practice clinicians. The evidence based treatment algorithm was then distributed to each provider. The protocol was monitored for three months. A post-implementation questionnaire was used to determine current practice after implementation of the treatment algorithm.
Results: Prior to implementing the protocol, the majority of respondents said they frequently faced a dilemma regarding VTE prophylaxis in neurosurgical patients. Participants reported that patient/hemorrhage characteristics including ‘size’, ‘type’, ‘location’ of hemorrhage and ‘patient comorbidities’ were important factors in their decision process. They also reported that ‘past experience’, ‘intuition/clinical judgment’, and ‘literature’, influenced their decision. Following implementation of the VTE protocol, it was unanimously agreed that a standardized algorithm would decrease provider dilemma. Most respondents found the algorithm ‘very useful’ saying it decreased dilemmas and that they were ‘very likely’ to use it again. Two respondents stated that the algorithm was now a basis for their treatment decisions.
Conclusions: This study appeared to decreased provider dilemma regarding when to initiate VTE chemoprophylaxis in traumatic intracranial hemorrhage.
Keywords: hemorrhage, subdural hematoma, epidural hematoma, anticoagulation
Objectives: 1) Recognize the high incidence of VTE in neurosurgical patients. 2) Identify what factors/characteristics providers use to justify their decisions about when to begin VTE chemoprophylaxis. 3) Understand the need for a standardized protocol regarding initiation of VTE chemoprophylaxis in traumatic intracranial hemorrhage.
Subject: Spine
Title: 2-Year Results of SIFI Prospective SI Jt Fusion Clinical Trial
Authors: Brad Duhon
Introduction: Sacroiliac Joint (SI Joint) dysfunction is becoming increasingly recognized as a source of low back pain. It has been reported to be the most common source of low back pain after lumbar fusion. Results of a 2-year prospective clinical trial are reported.
Methods: 172 patients across 26 sites with SI Jt dysfunction were enrolled and underwent minimally-invasive SI Joint fusion with the SI-Bone iFuse device. Structured assessments were analyzed at baseline as well as at 1, 3, 6, 12, 24 months post-operatively. Adverse events were collected throughout follow-up. All patients received a high-resolution CT at 1 year post-op.
Results: SI Joint pain was present for an average of 5.1 years prior to enrollment. SI Joint pain reduced from 79.8 at baseline to 26.0 at 24 months. Oswestry Disability Index (ODI) reduced from 55.2 to 31.5. The proportion of patients taking opioids reduced from 76% to 55%. CT scan performed at 1 year showed bone adherence to at least 2 implants on both sides of the SI Joint in 97% of patients. Revision rate at 2 years was 4.7%.
Conclusions: the iFuse procedure showed high rates of patient satisfaction, pain reduction, and improvements in quality of life.
Keywords: Sacroiliac, SI, Fusion, Prospective
Objectives: 1. Complication rate of iFuse from SIFI clinical trial 2. Reduction of SI Joint pain from SIFI clinical trial 3. Revision rates of SI joint fusion from SIFI clinical trial
Subject: Tumor
Title: Differences between intraoperative MRI FLAIR and T2 tumor volumes compared to postoperative corresponding volumes in glioma surgery.
Authors: Randy L. Jensen
Introduction: Intraoperative MRI is a useful tool in the operative management of human gliomas. In non-contrast enhancing gliomas, and to a lesser extent enhancing tumors, the T2 and FLAIR signals are important targets to determine target volumes for resection margins. We hypothesized that intraoperatively (IO) obtained MRI T2 and FLAIR signal volumes might not reflect corresponding post-operative volumes due to tumor edema after resection and brain manipulation.
Methods: We examined 100 patients, average age 49.5 (range 16-82) 37 females and 63 males, who underwent intraoperative imaging during glioma surgery. We excluded patients with postoperatively diagnosed non-glioma pathology or if a new vascular injury was identified on diffusion-weighted imaging. Volumetric assessment of T2 and FLAIR signals were performed using the OSRIX image analysis program and ratios calculated for intraoperative and post-operative ratios of FLAIR and T2 MRI sequences for each patient.
Results: We examined 6 grade I gliomas (DNET, ganglioglioma, JPA) with postop/intraop FLAIR ratios of 3.30 +/-3.16 and T2 ratios of 3.15+/-3.74. In a similar fashion we found that similar ratios of FLAIR and T2 images for 25 Low-grade astrocytomas were 10.85+/-18.34 and T2 of 9.24+/-15.49; 10 oligodendrogliomas of 1.95+/-1.19 for FLAIR and 2.04+/- 1.51 for T2; 8 Anaplastic Astrocytomas with 4.30+/-7.91 for FLAIR and 3.33+/-4.69 for T2; 5 Anaplastic oligodendrogliomas with 2.34+/-3.11 and 2.04 +/-2.43 and 46 Glioblastomas with 2.11+/-2.89 and 2.22 +/-3.28.
Conclusions: Postoperative FLAIR and T2 signal volumes are significantly significantly higher than intraoperatively obtained corresponding volumes for all gliomas studied. Further work will be required but this study questions the validity of T2 and FLAIR images obtained intraoperatively.
Keywords: intraoperative MRI, MR imaging, outcomes
Objectives: 1. Determine the role of intraoperative MRI in glioma surgery 2. Understand differences between intraoperative and postoperative MR imaging 3. Discuss implications of intraoperatively obtained T2 and FLAIR on patient outcomes
Subject: Tumor
Title: Transfrontal Transnasal Approach to Skull Base Tumors
Authors: Joel D. MacDonald
Introduction: Large lesions of the frontal skull base that extend into the upper nasopharynx pose a challenging surgical problem. The transfrontal craniotomy combined with a transnasal approach can facilitate surgical resection.
Methods: A surgical procedure database was queried for patients with large lesions of the anterior skull base with extension into the nasopharynx. A retrospective chart review was conducted to analyze the variety of pathologies and surgical techniques.
Results: Eight patients were identified with a variety of pathologies including adenocystic carcinoma, inverting papiloma, melanoma, esthesioneuroblastoma, squamous cell carcinoma, and juvenile neurangiofibroma. Combined transfrontal and transnasal approaches facilitated surgical resection in each case. No patient died within 12 months of surgery. One patient developed breakdown of the scalp incision that did not require surgical revision and one patient developed a recurrence of squamous cell carcinoma that resisted adjuvant therapy
Conclusions: A combined Transfrontal and transnasal surgical approach can facilitate surgical resection of large and complex lesions of the anterior skull base and upper nasopharynx.
Keywords: Skull Base, Transnasal, Transfrontal, Tumor
Objectives: 1. Participants will be able to describe the transfrontal transnasal approach. 2. Participants will be able to discuss typical lesions of the anterior skull base that extend to the upper nasopharynx. 3. Participants will be able to discuss the principle advantages and disadvantages of this approach.
Subject: Socioeconomic
Title: The evolution of continuing medical education and graduate medical education.
Authors: Randy L. Jensen
Introduction: Graduate medical education has evolved to a competency-based progression though residency training via the ACGME milestones project.
Methods: The impact of this program on neurosurgical training is discussed.
Results: Application of these same principles is becoming the expectation of continuing graduate education necessary for board-certified participating in maintenance of certification. The process of accreditation of CME meetings by the American Association of Neurological Surgeons Joint Sponsor ship committee is discussed. This will include identification of practice knowledge gaps, target audience educational needs, and developing meeting programs to bridge these practice gaps.
Conclusions: The challenges and opportunities in CME, educational design changes and the evolving CME system will be described and discussed.
Keywords:
Objectives: 1. Discuss competency based learning experiences 2. Review contemporary methods of continuing medical education 3. Review graduated medical education goals and methods.