Subject: Socioeconomic
Title: Avoiding Burnout and Finding Purpose in Neurosurgical Practice
Authors: John B Dietze
Introduction: There are few occupations that are as stressful as the practice of neurological surgery. If not managed effectively, the emotional and psychological toll can be devastating.
Methods: Burnout is defined as “as a drawback related to life-management difficulty combined with a state of vital exhaustion” (ICD-10 Version:2010). Symptoms include fatigue, cynicism, disconnectedness, anger problems, and guilt. The challenges associated with the practice of neurosurgery create an environment where the risk of burnout is high.
Results: The burnout rate among neurosurgeons is over 56% according to a 2012 survey of AANS members. Factors contributing to burnout include long work hours, strained interpersonal relationships due to the former, and liability concerns to name only a few. There is therefore a need to be intentional in adopting strategies which minimize exposure to this risk factors whenever possible.
Conclusions: A failure to appropriately manage stress not only adversely affects the quality of life for the provider and those with whom he is in relationship but also his patients. As such, maintenance of emotional and psychological health is of utmost importance toward the goal of providing the best possible care.
Keywords: Coping Mechanism, Stress, Burnout
Objectives: Be able to understand what burnout is and how to prevent it. Be able to identify strategies to cope with stressful situations. Be able to see the relationship between good emotional health and good patient care
Subject: Trauma
Title: Blast Injuries, Mass Casualties, and TBI
Authors: Brad Duhon
Introduction: Mass shootings and casualties are on the rise in the United States. While most data and experience with blast-type traumatic brain injuries. Understanding the mechanism, pathophysiology, treatment, and prognosis is a good idea….even for civilian neurosurgeons.
Methods: Literature review of TBI pathophysiology, treatment, and outcomes of Blast-type traumatic brain injury.
Results: Literature review of TBI pathophysiology, treatment, and outcomes of Blast-type traumatic brain injury.
Conclusions: Blast-type TBI is very common among active military. Understanding mechanism and pathophysiology could serve useful even among civilian neurosurgeons.
Keywords: Blast, TBI, Mass casualties
Objectives: 1. To better understand intracranial injury patterns with blast injuries 2. Ability to triage multiple patients with intracranial injuries 3. Understand physiology and outcomes of blast and penetrating head injuries.
Subject: Trauma
Title: Local brain tissue water content, a novel measure of injury in traumatic brain injury patients
Authors: Bornali Kundu; James Gee; Al-Wala Awad; Min S Park; Gregory W Hawryluk
Introduction: Brain edema predicts poor neurological outcomes in traumatic brain injury (TBI) patients, however, it is indirectly assessed by intracranial pressure (ICP) monitoring. Intraparenchymal thermal conductivity-based probes measure local cerebral blood flow but more recently have been used to derive a measure of tissue water (TW) content in the brain (i.e. local cerebral edema). Hypertonic saline boluses lower the TW content measure in neurosurgical patients. However, how this measure responds over time through a patient’s ICU course has yet to be established. We investigated whether TW content responds to hyperosmolar and hypothermic therapy administered over time in neurosurgical patients.
Methods: TBI patients with ICP monitoring placed due to poor neurological status were reviewed. A Camino Bolt (Integra Life Sciences Inc) monitoring system or an extraventricular drain was used. Patients were chemically paralyzed and cooled to a goal temperature of 34-35 degrees Celsius. A QFlow500 probe (Hemedex Inc.) was placed in the hemisphere containing more intact brain tissue according to current guidelines. Patient were monitored for several days. Correlation between TW and ICP, TW and serum sodium, and TW and temperature were calculated.
Results: N=15 patients were included in this study. Results showed that an ICP of 17-20 mmHg is related to 75-76% TW content. Overall, there is a negative relationship between TW and serum sodium, though this seems to depend on the prior state of the brain, i.e. time from injury. Bolusing with hypertonic saline was related to lower TW content. Finally, there is a positive correlation between TW and body temperature over time for the patients whom were cooled (n=3).
Conclusions: Local TW content is a novel measure that can be used as part of current multimodal neuromonitoring systems to allow for both global and local, targeted treatment of brain injury.
Keywords: cerebral blood flow, traumatic brain injury
Objectives: 1. State the principles of elevated ICP management in traumatic brain injury patients. 2. Know the recommended ranges of normal ICP, serum sodium, etc as stated in in the Brain Trauma Foundation Guidelines. 3. Describe the use of cerebral blood flow monitoring as a component of neuromonitoring in the ICU.
Subject: Cerebrovascular
Title: Cannabis, Reversible Cerebral Vasoconstriction Syndrome, and Cerebral Hemorrhage
Authors: Theodore C Larson
Introduction: If cannabis causes RCVS, and RCVS causes cerebral hemorrhage, then cannabis should cause cerebral hemorrhage. Although cannabis has been reported to cause RCVS and RCVS has been reported to cause cerebral hemorrhage, the association of cannabis and cerebral hemorrhage has not been emphasized.
Methods: Chart review of patients with confirmed cannabis use, intracranial hemorrhage, and catheter cerebral angiography was completed. Other illicit drug use, chronic hemorrhage, and hemorrhagic conversion of ischemic infarction were exclusion criteria.
Results: Six patients met inclusion criteria. All presented with HA, typically severe. Three had SAH, three had IPH, and two had PRES. All were diagnosed with RCVS on catheter cerebral angiography. Angiographic findings could be subtle. CTA was usually normal. Three patients developed seizures. One patient underwent brain biopsy that was negative.
Conclusions: Because of the prevalence of patients testing positive for cannabinoids, patients who present with intracranial hemorrhage should undergo diagnostic catheter cerebral angiography to determine if RCVS is the underlying etiology for appropriate management. Given the significant population that uses cannabis, the incidence of RCVS caused by cannabis is likely low.
Keywords: Cannabis, RCVS, Cerebral Hemorrhage
Objectives: 1. Cannabis causes RCVS and cerebral hemorrhage. 2. Catheter cerebral angiography is recommended to diagnose RCVS. 3. Angiographic findings of vasoconstriction can be subtle and CTA may be normal.
Subject: Trauma
Title: Blast Injuries and Mass Trauma
Authors: Brad Duhon
Introduction: Mass casualties and shootings have seen an alarming increase over the last 20 years. This review will discuss injury mechanisms, treatments, and outcomes from blast injuries and mass casualties.
Methods: Literature Review of data on Blast Injuries and Mass Casualties
Results: Much has been learned about blast injuries associated with mass casualties over the years. Proper recognition, triage, and treatment of blast injuries can lead to improved outcomes.
Conclusions: Much has been learned about blast injuries associated with mass casualties over the years. Proper recognition, triage, and treatment of blast injuries can lead to improved outcomes.
Keywords: Blast, TBI, Trauma, Casualties
Objectives: 1. Ability to triage with mass casualties 2. Minimizing secondary insult after blast injuries. 3. Understanding pathophysiology of blast injuries.
Subject: Spine
Title: Development of a Predictive Score for Discharge Disposition After Lumbar Fusion Using the Quality Outcomes Database
Authors: Jian Guan; John J Knightly; Erica Bisson
Introduction: Lumbar fusion remains the treatment of choice for a variety of degenerative pathologies. Healthcare costs related to the procedure are an area of concern, and post-discharge needs often contribute to greater expenditure. The Quality Outcomes Database (QOD) is a prospective, multi-center clinical registry designed specifically to analyze outcomes after neurosurgical procedures. We sought to create a simple scoring system to predict discharge needs after lumbar fusion using the QOD.
Methods: Institutional QOD data from two high-volume neurosurgical centers were collected for analysis. Univariate and multivariable logistic regression analyses were used to identify factors for our model. A receiver operating characteristic curve was used to set cutoff scores for patients likely to discharge home without needing ongoing services and those likely to require additional services/alternative placement after hospital discharge.
Results: Two hundred seventeen patients were included to build our model. Five variables—osteoporosis, predominant preoperative symptom, need for assistive device for ambulation, American Society of Anesthesiologist grade, and age—were included in our final scoring system, in which patients with higher scores are less likely to need additional services. In patients with high scores (8–10), our scale correctly predicted discharge needs in 88.7% of cases. In patients with low scores (0–5), our scale predicted discharge needs (additional home services/alternative placement) in 75% of cases. For our final instrument, the area under the curve for our receiver operating characteristic curve was 0.809 (95% CI 0.720–0.897).
Conclusions: We present a simple scoring system that may be utilized to assist in predicting postdischarge needs for patients undergoing lumbar fusion for degenerative disease. Further validation studies are needed to assess the generalizability of our scale.
Keywords: Lumbar fusion, predictive scores, quality outcomes database, discharge disposition
Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of discharge planning in lumbar fusion surgery. 2) Discuss, in small groups the utility of our scoring system for predicting discharge needs following lumbar fusion. 3) Identify an effective intervention for possibly reducing costs related to lumbar fusion using our scoring system.