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Measuring Value of Health Care: The Importance and Challenges of Measuring True Cost

Health care expenditure has become one of the largest spending items for any nation. Specifically, in developed nations, health care expenditure is not only on the rise, but it is following an unsustainable trajectory. It was been well documented that the United States, in comparison to similar well-developed nations, spends a relatively large percent of its gross domestic product (GDP) on health care expenditure. However, by…

The Role of Clinical Registries in Health Care

Health Care Reform in the United States Measuring and improving the quality of surgical health care is an increasingly important goal in understanding the overall value, contribution, and impact surgical care has on the American Healthcare system. The current growth rate of health care costs in the United States is unsustainable, and therefore the ability to define real-world effectiveness of health care delivery is of vital…

On Developing the Tools and Metrics for a Neurosurgical Quality Program

Over the past two plus decades, the entire landscape of healthcare has shifted and continues to evolve. More patients are receiving both care and increasingly complex treatments. The quality of care and the cost of that care have become significant issues. As a result, many are of the belief that the quality is poor and the system is wasteful. Indeed, a “wake-up call” was delivered in…

Clinical Research in Quality Improvement: Complementary Approaches to Improving Neurosurgical Practice

Introduction Practicing neurosurgeons should be involved in a continuous, ongoing process of improving the results of their clinical interactions with patients. For the individual surgeon, this might include a process for self-improvement, such as continuing education or maintenance of certification. The process of improving clinical care overall relies principally on functions that are more broadly applied. The predominant methods for doing this are clinical research and…

The History and Future of Quality and Safety in Neurosurgery

Introduction: The Perspective From Patient Safety Science The practice of neurological surgery has always attracted a select group of highly motivated individuals. These practitioners typically possessed qualities of excellence and the pursuit of the best outcomes. Neurosurgical training programs recruited the brightest minds with stellar test scores and demonstrable academic skills. These trainees were taught to maximize personal performance and hone their skills in order to…

The Many Perspectives of Quality and Safety in Neurosurgery

Introduction The importance of the details of caring for a neurosurgical patient has increasingly become the focus of many groups that are involved in the patient's clinical care. In large part, this focus has been driven by the field of quality and safety or quality improvement (QI). Patients have long assumed that their best interests were at the forefront of the care they experience in the…

Prehospital Neurotrauma

Clinical Pearls Our role as clinician-scientists is to minimize secondary brain injury, meaning evolving pathologies from the moment of impact. Hence, if the impact has not killed the patient, there is opportunity to intervene and minimize further morbidity or mortality. There are many types of traumatic brain injuries, but because we cannot diagnose on scene, they are all managed identically. On-scene diagnostics may enable brain injury–specific…

Entrapment Neuropathies and Peripheral Nerve Tumors

Clinical Pearls To understand the diseases of the peripheral nerve system, physicians require anatomic awareness about the course of the peripheral nerves, bony landmarks, and the relevant ligaments and key muscles Furthermore, a working knowledge about how the muscles function is crucial in order to properly diagnose peripheral nerve system problems. Entrapment neuropathy is a subgroup of acquired peripheral neuropathies. It occurs when a peripheral nerve…

Management of Peripheral Nerve Injuries

Clinical Pearls Peripheral nerve injuries affect 2.8% of trauma patients. One of the important features of the peripheral nervous system in comparison with the central nervous system is its capacity for recovery through both regeneration and remyelination of axons. The ultimate goal of managing peripheral nerve injuries is to deliver the optimum treatment. This comes from proper determination of the injured nerve(s) as well as the…

Hydrocephalus in Adults

Clinical Pearls Hydrocephalus is defined as disturbances in cerebrospinal fluid dynamics. Acute hydrocephalus and shunt obstruction are neurosurgical emergencies. Cerebrospinal fluid drainage shunts are the main treatment option of hydrocephalus. However, shunt complications are relatively common. Endoscopic third ventriculostomy is an alternative treatment option in patients with obstructive hydrocephalus. The term hydrocephalus is a modern Latin adaptation from Greek hudrokephalon, from húdōr (“water”) + kephalē (“head”).…

Surgical Management of Infection of the Central Nervous System, Skull, and Spine

Clinical Pearls Brain abscesses are mostly caused by hematogenous spread, contiguous spread, and trauma. Contiguous spread is generally from a purulent frontoethmoidal sinusitis or an infected mastoid. Pyogenic brain abscesses are multibacterial; however, Streptococcus sp. is the most common pathogen. Capsule removal of parenchymal brain abscesses prevents recurrence. Spine infections cause rapid neurologic deterioration and become a neurosurgical emergency. Advanced osteomyelitis of the spine may require…

Stereotactic Functional Neurosurgery for Mental Health Disorders, Pain, and Epilepsy

Clinical Pearls Modern stereotactic functional surgery includes lesioning and stimulation procedures. Both have their advantages and disadvantages, and their choice should be tailored to the therapeutic aims and circumstances in the individual patient. Evidence for the efficacy of stereotactic surgery in mental health disorders has been variable. Randomized controlled trials have provided level 1 evidence of efficacy of functional neurosurgery for obsessive-compulsive disorder and Tourette syndrome.…

Deep Brain Stimulation for Movement Disorders

Clinical Pearls Functional neurosurgery involves precise surgical targeting of anatomic structures in order to modulate neurologic function. Deep brain stimulation (DBS) has become the standard of care for movement disorders because of its early reversibility and flexibility as well as the ability to perform simultaneous bilateral interventions with a low incidence of adverse effects. DBS is a lifelong therapy. Neurosurgeons, neurologists, and allied health care specialists…

Extratemporal Procedures and Hemispherectomy for Epilepsy

Clinical Pearls Intractable disabling epilepsy, a localizable epileptogenic zone, and a low risk of (unacceptable) postoperative deficits are considered to be the three basic tenets that make a patient a candidate for epilepsy surgery. One should apply surgical technique for extratemporal resections to match the underlying cause and functional boundaries. Functional hemispherectomy techniques are especially effective in disease states involving one hemisphere, such as perinatal stroke,…

Surgery for Temporal Lobe Epilepsy

Clinical Pearls The most common medically intractable epilepsy appropriate for epilepsy surgery has a temporal lobe origin. Mesial temporal lobe epilepsy represents a large percentage of all cases of localization-related epilepsy. The seizures arise in the hippocampal and parahippocampal areas and in the amygdala. Mesial temporal lobe epilepsy also presents common diagnostic features including unilateral interictal and ictal electroencephalography and magnetic resonance imaging features showing sclerosis…

Spasticity : Classification, Diagnosis, and Management

Clinical Pearls Spasticity is a form of hypertonia that becomes more pronounced with the increasing speed of passive muscle stretch or passive motion beyond a critical angle. The disorder results from upper motor neuron lesions, such as cerebral palsy, stroke, or spinal cord injury. Physical and occupational therapies are central to the care of patients with spasticity. Tone reduction with botulinum toxin and oral antispasmodics such…

Trigeminal Neuralgia

Clinical Pearls Careful clinical diagnosis is key to appropriately selecting patients who will benefit from surgical treatments for trigeminal neuralgia. During microvascular decompression, the entire cisternal segment of cranial nerve V must be inspected from the brainstem to the entrance into Meckel's cave. It is not uncommon to identify multiple offending vessels, all of which require decompression for optimal results. Treatment recommendations should be tailored to…

Description of Proton Therapy

Clinical Pearls Unlike photons, protons deposit a localized peak of dose known as the Bragg peak. In the absence of exit radiation dose, nearby normal organ structures may be spared dose, which may translate to reduced toxicity (eg, neurocognition, endocrine dysfunction, secondary malignancies) or allow dose escalation to improve local control. The benefits of proton therapy are best exemplified in medulloblastoma patients, who are treated to…

Radiosurgery of Central Nervous System Tumors and Arteriovenous Malformations

Clinical Pearls Randomized controlled and prospective trials have established a survival advantage and high local control rates after stereotactic radiosurgery for metastatic disease to the CNS, including for up to 10 brain metastases. Matched cohort studies comparing Gamma Knife radiosurgery to surgical resection of vestibular schwannomas report similar tumor control rates for small and medium-sized tumors. However, Gamma Knife radiosurgery reduces the rates of facial weakness…

Application of Current Radiation Delivery Systems and Radiobiology

Clinical Pearls Radiation therapy relies on delivering energy to tissues, which ultimately disrupts cellular function through DNA damage. The physics of high-energy photons or charged particles determine the delivery profile of energy and its biologic effects. Historically developed by neurosurgeons, radiosurgery is the use of precise stereotactic techniques to deliver high-dose radiation in a single or few fractions. Many radiosurgery and radiation therapy delivery systems are…