Neurosurg Focus
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Review
Perioperative management of complex skull base surgery: the anesthesiologist's point of view.
The anesthetic management of complex skull base surgical procedures provides unique problems and concerns for the neuroanesthesiologist. Positioning to access the skull base could put the patient at risk for peripheral nerve injury and some of the positions may increase the risk for air emboli. In addition, tumor pathology and involvement with vital structures could increase the chances for substantive blood loss, destruction of associated nerves or vessels, and may require temporary occlusion of the carotid artery necessitating intraoperative neuroprotection. ⋯ The authors discuss the anesthetic concerns and management for complex cranial base surgery. Different approaches will be discussed and comparisons of perioperative parameters between these approaches will be made with data provided by retrospective chart review of more than 600 skull base procedures performed at the authors' institution over the last 10 years. This information should help guide decision making concerning anesthetic management for these skull base procedures.
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Although many treatment strategies for skull base tumors in adults have been reported, relatively little has been reported regarding such therapies in the pediatric population. Skull base tumors in children present a therapeutic challenge because of their unique pathological composition, the constraints of the maturing skull and brain, and the small size of the patients. In this review, the authors examine the pediatric skull base lesions that occur in the anterior, middle, and posterior cranial base, focusing on unique pediatric tumors such as encepahalocele, fibrous dysplasia, esthesioneuroblastoma, craniopharyngioma, juvenile nasopharyngeal angiofibroma, cholesteatoma, chordoma, chondrosarcoma, and Ewing sarcoma. ⋯ Evidence for the advantages and limitations of radiotherapy, chemotherapy, and surgery as it pertains to the pediatric population will be examined. With a working knowledge of skull base anatomy and special considerations of the developing craniofacial skeleton, neurosurgeons can treat skull base lesions in children with acceptable morbidity and mortality rates. Outcomes in this population may be better than those in adults, in part because of the benign histopathology that frequently affects the pediatric skull base, as well as the plasticity of the maturing nervous system.
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Patients expect and deserve quality medical care. Physicians, by nature, want what is best for their patients. With the advent of specialty hospitals, physicians can own, run, and control a superior center designed to deliver the highest quality health care. Neurosurgeons who manage their own hospital may set the standards for medical excellence, with patient satisfaction as their primary focus.
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Current Procedural Terminology (CPT) standardizes medical procedure coding for billing and reimbursement. Since adoption of CPT coding as the basis for the Medicare Fee Schedule (MFS) in 1992, CPT coding policies and policy changes have been influenced not only by medical necessity and customary practice, but also increasingly by Medicare payment policies. The MFS created regulatory price control in the United States medical market based on widespread adoption of modified MFS by private payers and benchmark MFS fees governed by federal budget limitations and set annually by government agency (Centers for Medicare and Medicaid Services).
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Payment for physician services in the United States is directly tied to the payment system implemented in the Medicare system. The use of a code to categorize medical and surgical services, as well as a relative value system to assess physician services and reimburse them accordingly, is now well established. In light of this, it is important for physicians to possess knowledge of how this coding and reimbursement system was established, how it is updated, what means are available to modify it, and how it is used in practice. The author addresses these issues, offering a primer for the neurosurgeon on the Medicare system as it relates to physician payment.