A Primer on Cognitive Errors Illustrated Through the Lens of a Neurosurgical Practice

Problem Statement: Diagnostic error is often attributed to cognitive errors, including biased thinking patterns, rather than knowledge or data limitations, and education on cognitive bias deserves review in all spheres of practice. Background: The cognitive biases of practitioners create an inherent fallibility in recognizing and treating medical conditions. Awareness of cognitive errors is valuable for mitigating risk of diagnostic error. The impact of cognitive error is substantial in the management of neurosurgically relevant disease. Remarkably broad differential diagnoses often accompany neurologic symptoms. Both focal and non-focal symptoms lend themselves to diagnostic inertia that contributes to errors. Further, initial diagnostic direction can be inaccurate in the involved biological system, anatomic localization, and the pathologic process; thus delaying diagnosis and potentially courting severe consequences. The authors present neurosurgical cases to illustrate the major types of unconscious cognitive errors in medicine using clinically relevant vignettes. Strategies to mitigate cognitive error are also reviewed. Application/Recommendations: Awareness of the types of cognitive errors and de-biasing strategies are valuable to avoid faulty estimation of disease likelihood, avoid overlooking all relevant possibilities, and mitigate error in critical thinking. Recognition that all clinicians are vulnerable to cognitive error exposes the importance of strategies to reduce biases. Efforts to reduce error in medicine can be approached strategically by working to reduce bias and increase discipline in clinical reasoning

Telemedicine and the right to health: A neurosurgical perspective

Neurosurgical task force is limited and unevenly distributed. Telemedicine has become increasingly popular, and could help neurosurgical centers meet patient right to care. This scoping review aims to evaluate the impact and feasibility of telemedicine on the right to neurosurgical care, using the AAAQ toolbox. The AAAQ toolbox consists of Availability, Accessibility, Acceptability and Quality. Neurosurgical availability is limited by the number of neurosurgeons, but by using task shifting and -sharing via telemedicine, the number of patients receiving neurosurgical care could increase without increasing the number of neurosurgeons. Telemedicine can improve geographic accessibility to neurosurgical care, but may also introduce technological literacy barriers. Acceptability of telemedicine is a double-edged sword; while a useful service, telemedicine also creates ethical concerns regarding privacy and confidentiality. Regulations and adaptations for vulnerable patient groups are key considerations for deploying telemedicine. Finally, there is emerging evidence that the quality of remote neurosurgical diagnostics and care can keep high standards. Overall, telemedicine has the potential of taking neurosurgery one step closer to meeting patient right to health, globally

A Primer on Cognitive Errors Illustrated Through the Lens of a Neurosurgical Practice

Problem Statement: Diagnostic error is often attributed to cognitive errors, including biased thinking patterns, rather than knowledge or data limitations, and education on cognitive bias deserves review in all spheres of practice. Background: The cognitive biases of practitioners create an inherent fallibility in recognizing and treating medical conditions. Awareness of cognitive errors is valuable for mitigating risk of diagnostic error. The impact of cognitive error is substantial in the management of neurosurgically relevant disease. Remarkably broad differential diagnoses often accompany neurologic symptoms. Both focal and non-focal symptoms lend themselves to diagnostic inertia that contributes to errors. Further, initial diagnostic direction can be inaccurate in the involved biological system, anatomic localization, and the pathologic process; thus delaying diagnosis and potentially courting severe consequences. The authors present neurosurgical cases to illustrate the major types of unconscious cognitive errors in medicine using clinically relevant vignettes. Strategies to mitigate cognitive error are also reviewed. Application/Recommendations: Awareness of the types of cognitive errors and de-biasing strategies are valuable to avoid faulty estimation of disease likelihood, avoid overlooking all relevant possibilities, and mitigate error in critical thinking. Recognition that all clinicians are vulnerable to cognitive error exposes the importance of strategies to reduce biases. Efforts to reduce error in medicine can be approached strategically by working to reduce bias and increase discipline in clinical reasoning

Lower motor neuron findings after upper motor neuron injury: insights from postoperative supplementary motor area syndrome.

Hypertonia and hyperreflexia are classically described responses to upper motor neuron injury. However, acute hypotonia and areflexia with motor deficit are hallmark findings after many central nervous system insults such as acute stroke and spinal shock. Historic theories to explain these contradictory findings have implicated a number of potential mechanisms mostly relying on the loss of descending corticospinal input as the underlying etiology. Unfortunately, these simple descriptions consistently fail to adequately explain the pathophysiology and connectivity leading to acute hyporeflexia and delayed hyperreflexia that result from such insult. This article highlights the common observation of acute hyporeflexia after central nervous system insults and explores the underlying anatomy and physiology. Further, evidence for the underlying connectivity is presented and implicates the dominant role of supraspinal inhibitory influence originating in the supplementary motor area descending through the corticospinal tracts. Unlike traditional explanations, this theory more adequately explains the findings of postoperative supplementary motor area syndrome in which hyporeflexia motor deficit is observed acutely in the face of intact primary motor cortex connections to the spinal cord. Further, the proposed connectivity can be generalized to help explain other insults including stroke, atonic seizures, and spinal shock

Appraisal of the Quality of Neurosurgery Clinical Practice Guidelines.

OBJECTIVE: The rate of neurosurgery guidelines publications was compared over time with all other specialties. Neurosurgical guidelines and quality of supporting evidence were then analyzed and compared by subspecialty. METHODS: The authors first performed a PubMed search for Neurosurgery and Guidelines. This was then compared against searches performed for each specialty of the American Board of Medical Specialties. The second analysis was an inventory of all neurosurgery guidelines published by the Agency for Healthcare Research and Quality Guidelines clearinghouse. All Class I evidence and Level 1 recommendations were compared for different subspecialty topics. RESULTS: When examined from 1970-2010, the rate of increase in publication of neurosurgery guidelines was about one third of all specialties combined (P \u3c 0.0001). However, when only looking at the past 5 years the publication rate of neurosurgery guidelines has converged upon that for all specialties. The second analysis identified 49 published guidelines for assessment. There were 2733 studies cited as supporting evidence, with only 243 of these papers considered the highest class of evidence (8.9%). These papers were used to generate 697 recommendations, of which 170 (24.4%) were considered Level 1 recommendations. CONCLUSION: Although initially lagging, the publication of neurosurgical guidelines has recently increased at a rate comparable with that of other specialties. However, the quality of the evidence cited consists of a relatively low number of high-quality studies from which guidelines are created. Wider implications of this must be considered when defining and measuring quality of clinical performance in neurosurgery

Atlantoaxial Spondyloptosis with Type II Odontoid Fractures: A Report of 2 Cases

CASE: Two patients with delayed presentations of neck pain and fixed kyphotic deformity after trauma were found to have atlantoaxial spondyloptosis (AAS) with type II dens fractures. Owing to the rarity of AAS, outcomes and optimal treatment are not well understood. In both cases, closed reduction was achieved with a dynamic overhead traction setup, followed by posterior surgical stabilization with C1-2 screw fixation. CONCLUSION: Closed reduction remains a challenge because of the marked deformity of interlocking C1-C2 joints. However, patients with chronic fixed atlantoaxial dislocation due to odontoid fractures can be safely managed with closed reduction and fusion of C1-C2. LEVEL OF EVIDENCE: Level V

A protocol for postoperative admission of elective craniotomy patients to a non-ICU or step-down setting.

OBJECTIVE Selecting the appropriate patients undergoing craniotomy who can safely forgo postoperative intensive care unit (ICU) monitoring remains a source of debate. Through a multidisciplinary work group, the authors redefined their institutional care process for postoperative monitoring of patients undergoing elective craniotomy to include transfer from the postanesthesia care unit (PACU) to the neurosurgical floor. The hypothesis was that an appropriately selected group of patients undergoing craniotomy could be safely managed outside the ICU in the postoperative period. METHODS The work group developed and implemented a protocol for transfer of patients to the neurosurgical floor after 4-hour recovery in the PACU following elective craniotomy for supratentorial tumor. Criteria included hemodynamically stable adults without significant new postoperative neurological impairment. Data were prospectively collected including patient demographics, clinical characteristics, surgical details, postoperative complications, and events surrounding transfer to a higher level of care. RESULTS Of the first 200 consecutive patients admitted to the floor, 5 underwent escalation of care in the first 48 hours. Three of these escalations were for agitation, 1 for seizure, and 1 for neurological change. Ninety-eight percent of patients meeting criteria for transfer to the floor were managed without incident. No patient experienced a major complication or any permanent morbidity or mortality following this care pathway. CONCLUSIONS Care of patients undergoing uneventful elective supratentorial craniotomy for tumor on a neurosurgical floor after 4 hours of PACU monitoring appears to be a safe practice in this patient population. This tailored practice safely optimized hospital resources, is financially responsible, and is a strong tool for improving health care value

How to Transect the C2 Root for C1 Lateral Mass Screw Placement: Case Series and Review of an Underappreciated Variable in Outcome.

BACKGROUND: The techniques for atlantoaxial arthrodesis have been modified over the years, and placing C1 lateral mass screws is a modern approach. C2 neuropathy is a complication of concern; however, sacrifice of the C2 nerve is an accepted and often favored adjunct. The impact of the technique for cutting the C2 nerve is not adequately addressed in the literature. The aim of this study was to evaluate the clinical outcomes from a series of roots sacrificed during C1-2 fusion with attention to the C2 transection method. METHODS: Clinical data were collected from trauma patients who underwent C1 screw fixation for atlantoaxial fusion. Chart review was performed and outcome assessed through telephone surveys to patients who were at least 6 months postoperative. Quality of life, C2 nerve function, neck pain, and head pain were assessed. RESULTS: Sixty-six roots were divided in 35 patients. There were no cases of occipital neuralgia at routine 3-month follow-up. Delayed telephone surveys were completed in 17 patients and exposed 4 cases of severe head/neck pain but none consistent with occipital neuralgia. CONCLUSIONS: C2 neuralgia is rare when sharply dividing the C2 root with the aid of bipolar electrocautery at the midportion of the ganglion where it overlies the C1-2 joint. A literature review suggests the impact of the root sacrifice method is an underappreciated modifiable factor in outcome. In future reports, description of the root transection technique is imperative and trials comparing ganglionectomy versus transection proximal to the ganglion or through the ganglion should be considered

Awake Craniotomy Without Invasive Blood Pressure Monitoring

OBJECTIVE: The aim of this study was to assess the safety of foregoing invasive monitoring in a select group of patients undergoing awake craniotomy for supratentorial tumor resection. METHODS: Awake craniotomies were performed for tumor resection without invasive BP monitoring when there was no pre-existing cardiopulmonary indication as determined by the attending anesthesiologist according to institutional protocol. Non-invasive monitoring was performed every 3-5 minutes intraoperatively and then every 15 minutes in the recovery room for 4 hours before transfer to the ward. RESULTS: Seventy-four consecutive awake surgeries were performed with non-invasive BP monitoring at a single tertiary care hospital. 42 (83.8%) had infiltrative primary brain tumors, 39 (52.7%) were male, 2 (2.7%) had history of coronary artery disease, 6 (8.1%) were diabetics and 10 (29.7%) were smokers. 22 of the 74 (29.7%) patients were on antihypertensive medications preoperatively. American Society of Anesthesiologists (ASA) classification was I in 1.4%, II in 36.4%, III in 60.8% and IV in 1.4%. Twenty-one (28.4%) received intraoperative vasoactive medications and eight (38%) of these were on antihypertensive agents preoperatively. Of these 21, thirteen (61.9%) received vasodilators, six (28.6%) received vasopressors and two (9.5%) were dosed with both vasodilators and vasopressors. One patient had a lenticulostriate artery stroke intraoperatively and one patient had atrial fibrillation one week postoperatively. There were no other perioperative anesthetic, hemorrhagic, renal or cardiopulmonary complications. CONCLUSIONS: Intraoperative physiologic control and surgical site complication avoidance do not warrant routine invasive BP monitoring during awake craniotomy for tumor resection