Neurosurgery
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With rising health care costs, clinical outcome data are becoming increasingly important. The concept of minimally clinical important difference (MCID) has been shown to be effective in spine surgery to differentiate between clinically insignificant and significant improvements and to measure the patient's perspective of quality of life and disability. We sought to determine the MCID for spinal cord stimulation (SCS) therapy for failed neck and back syndromes, which has not been established to date. ⋯ The MCID for SCS placement was calculated by using 4 methods. The results are similar to calculations for the MCID for traditional surgical procedures done for pain. Our results suggest that an improvement of 1.2 to 3.7 points on the VAS scale and 8.2 to 13.3 points on the ODI is clinically meaningful to the patient. Further defining the MCID for SCS therapy will remain of utmost importance in order to justify the cost of the procedure.
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Delivery of higher-value health care is an ultimate government and public goal. Improving efficiency in the operating room and standardization of surgical steps would improve patient outcome and reduce costs, and lead to higher-value health care. Lean principles have been applied to processes proceeding and following surgery and have improved timeliness; however, value stream mapping of surgery itself has not been performed; therefore, pure waste has not been targeted for improvement. We applied plan, do, study, act (PDSA) cycles to posterior instrumented fusion (PIF) in an attempt create a standard work flow, identify waste, and remove special cause variability among similar cases. ⋯ Lean principles can be applied to neurosurgical procedure time, and can be used to standardize surgical workflow and identify waste; common to all procedures was waiting and defect waste from nonsurgical sources. These preliminary data were the basis of a quality improvement Kaizen event to decrease the causes of variability, improve efficiency, and decrease overall cost.
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Concussion remains a clinical diagnosis with the lack of objective changes on standard brain imaging. Failure to document concussion delays appropriate intervention in this at-risk population. Magnetoencephalography (MEG) is a powerful, noninvasive imaging modality which may offer unique insight into functional brain networks affected in concussed patients. ⋯ These results suggest that short-duration MEG recording may be used to diagnose concussion. MEG can be used to calculate an objective measure quantifying the degree of global dysfunction that potentially can be used to predict functional outcomes or symptom severity. This is the first study to apply graph theory on MEG-acquired data in concussion.
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Previous studies have demonstrated a profound dysfunction of cerebral metabolism following traumatic brain injury (TBI). Despite overall depression of cerebral metabolism, the cerebral metabolic rate (CMR) of oxygen is depressed out of proportion to the mildly reduced CMRglucose. This mismatch has raised the question, where does the missing glucose go if it is not metabolized oxidatively? We have previously demonstrated that an increased proportion of glucose is shunted through the pentose phosphate pathway prompting us to further investigate the total percentage of glucose metabolized by alternative pathways (the "missing glucose") in an attempt to understand the full milieu of altered or dysfunctional metabolism in the injured brain. ⋯ In addition to an overall depression of cerebral metabolism for oxygen and glucose, the percentage of glucose with alternative metabolic fates (missing glucose) was significantly higher in the posttraumatic brain than in the normal brain, almost a 3-fold elevation. Further study is needed to fully identify the alternative metabolic pathways involved.
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Previous studies have documented dysfunctional cerebral metabolism following traumatic brain injury (TBI), characterized by reduction in cerebral metabolic rates (CMRs) of glucose and oxygen. In our largest series to date, here, we provide further evidence and time courses of these metabolic changes. ⋯ In our largest series of patients to date, we have demonstrated that posttraumatic cerebral metabolism is characterized by depressed glucose and oxygen metabolism that is persistent for at least 6 days postinjury. There is mismatch between glucose and oxygen utilization, indicated by diminished metabolic ratio, and frequent lactate uptake. Further study is required to fully characterize the dysfunctional metabolism, which may be a source of further secondary injury in the early postinjury period.