Neurosurg Focus
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Knowledge of the costs incurred through the delivery of neurosurgical care has been lagging, making it challenging to design impactful cost-containment initiatives. In this report, the authors describe a detailed cost analysis for pituitary surgery episodes of care and demonstrate the importance of such analyses in helping to identify high-impact cost activities and drive value-based care. ⋯ After completing a detailed assessment of costs incurred throughout the management of patients undergoing pituitary surgery, high-yield opportunities for cost containment should be identified among the most expensive activities and/or those with the highest variation. Strategies for safely reducing the use of the targeted resources, and related costs incurred, should be developed by the multidisciplinary team providing care for this patient population.
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Indirect costs of the interview tour can be prohibitive. The authors sought to assess the desire of interviewees to mitigate these costs through ideas such as sharing hotel rooms and transportation, willingness to stay with local students, and the preferred modality to coordinate this collaboration. A survey link was posted on the Uncle Harvey website and the Facebook profile page of fourth-year medical students from 6 different medical schools shortly after the 2014 match day. ⋯ Among postinterview students, communication was preferred to be by private, email identification-only chat room. Given neurosurgery resident candidates' interest in collaborating to reduce interview costs, consideration should be given to creating a system that could allow students to coordinate cost sharing between interviewees. Moreover, interviewees should be connected to local students from neurosurgery interest groups as a resource.
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In the United States in recent years, a dramatic increase in the use of intraoperative neurophysiological monitoring (IONM) during spine surgeries has been suspected. Myriad reasons have been proposed, but no clear evidence confirming this trend has been available. In this study, the authors investigated the use of IONM during spine surgery, identified patterns of geographic variation, and analyzed the value of IONM for spine surgery cases. ⋯ As costs of spine surgeries continue to rise, it becomes necessary to examine and justify use of different medical technologies, including IONM, during spine surgery.
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In patients with posterior fossa arteriovenous malformations (AVMs) who present with hemorrhage, feeding artery aneurysms are often the source of bleeding. The aim of this study was to evaluate the relative proportions of cases of infra- and supratentorial AVMs in which patients presented with prenidal aneurysm rupture. The management and outcome of 9 cases of posterior fossa AVMs associated with prenidal aneurysm rupture are presented. ⋯ Posterior fossa AVM hemorrhages are frequently associated with prenidal arterial aneurysms. Urgent endovascular treatment of the aneurysm was effective in this case series.
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Intracranial or brain arteriovenous malformations (BAVMs) are some of the most interesting and challenging lesions treated by the cerebrovascular neurosurgeon. It is generally believed that the combination of BAVMs and intracranial aneurysms (IAs) is associated with higher hemorrhage rates at presentation and higher rehemorrhage rates and thus with a more aggressive course and natural history. There is wide variation in the literature on the prevalence of BAVM-associated aneurysms (range 2.7%-58%), with 10%-20% being most often cited in the largest case series. ⋯ The ultimate goals of the treatment of a BAVM associated with an IA are to prevent hemorrhage, avoid stepwise neurological deterioration, and eliminate the mortality risk associated with recurrent hemorrhagic events. The treatment is only justifiable if the risks associated with an intervention are lower than or equivalent to the long-term risks of disability or mortality caused by the lesion itself. When faced with this difficult decision, a few questions need to be answered by the treating neu-rosurgeon: What is the mode of presentation? What is the symptomatic lesion? Which one of the lesions bled? What is the relationship between the BAVM and IA? Is it possible to safely treat both BAVM and IA? The objective of this review is to discuss the demographics, natural history, classification, and strategies for management of BAVMs associated with IAs.