Credentialing, Certification, and Peer Review Essentials for the Neurosurgeon

Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician\u27s competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries

Spinal dural attachments to the vertebral column: An anatomic report and review of the literature

BACKGROUND: The spinal dura is anchored within the vertebral canal by connective tissue in the epidural space as well as the spinal roots. Inadvertent disruption of these dural attachments may lead to durotomy and cerebrospinal fluid (CSF) leaks. We observed well-developed connective tissue ligaments connecting the lumbar dura to the spinal column and examined these tissues microscopically. METHODS: Intraoperative images were obtained during lumbar laminectomy procedures. They demonstrated connective tissue attachments, linking the lumbar dura to the spinal column in the dorsal midline and dorsolaterally. Tissue samples were obtained and examined microscopically. We then conducted a search of the literature to find references to dural attachments to the spinal column. RESULTS: Histological examination of the samples showed minimal cellular fibrous tissue. To date no references to these attachments have been made in neurosurgical literature. Previous studies, including live, cadaveric, and radiographic examinations, have demonstrated a dorsomedian fold of dura attached to the junction of the ligamentum flavum, and dorsolateral ligaments that divide the dorsal epidural space into an anterior and posterior compartment. CONCLUSIONS: Epidural fibrous connections or ligaments between the dura and the lumbar spinal column may be of clinical importance to the neurosurgeon. Care should be taken during lumbar procedures not to disrupt or tear these ligaments as this may cause dural tears and CSF leaks. Identifying these ligaments and cutting them sharply may prevent inadvertent durotomies

Comparative Effectiveness Analysis of Treatment Options for Single Brain Metastasis

Background Brain metastases (BMs) occur in up to 30% of patients with cancer. Treatments include surgery, whole-brain radiotherapy (WBRT), and stereotactic radiosurgery (SRS), alone or in combination. Although guidelines exist, data to inform individualized approaches to therapy remain sparse. We sought to compare semiquantitatively the effectiveness of various modalities in the treatment of single brain metastasis. Methods We performed a comparative effectiveness analysis (CEA) that integrated efficacy, cost, and quality of life (QoL) data for alternate BM treatments. Efficacy data were obtained from a comprehensive review of current literature. Cost estimates were based on publicly available data. QoL data included the Karnofsky Performance Status (KPS) and other questionnaires. Six treatment strategies using combinations of surgery, WBRT, and SRS were compared with decision tree software. Results The clinical efficacy, cost, and QoL effects of each strategy were scored semiquantitatively. We constructed a model to integrate individual preferences regarding the relative importance of efficacy, QoL, and cost to provide personalized rankings of the effectiveness of each strategy. Conclusion The choice of strategy must be individualized for patients with a single BM. Our CEA and decision model combines empirical data with patient priorities to produce a ranking of alternate management strategies

Conservative management of a cervical ligamentum flavum hematoma: Case report

BACKGROUND: Spontaneous epidural hematoma arising from the ligamentum flavum is a rare cause of acute spinal cord compression. There are only four reports in the cervical spine literature, and all were managed with surgery. Here, we describe an acute case of a spontaneous epidural hematoma arising from the ligamentum flavum in the cervical spine successfully managed without surgery. CASE DESCRIPTION: A 69-year-old woman with a cervical spine epidural hematoma contained within the ligamentum flavum presented with paroxysmal neck pain and stiffness without a history of trauma. The magnetic resonance imaging (MRI) revealed a posterolateral epidural hematoma contained within the ligamentum flavum. As the patient was intact, she was managed conservatively with cervical orthosis. Three months later, she was symptom-free, and the hematoma resolved on the follow-up MRI study. CONCLUSION: Spontaneous epidural hematoma arising from ligamentum flavum is a rare cause of spinal cord compression. Previous reports have described success with surgical decompression. However, initial observation and conservative management may be successful as illustrated in this case

Cushing-type ectopic pituitary adenoma with unusual pathologic features

AbstractEctopic pituitary adenomas comprise, by varying reports, approximately 1-2% of all pituitary adenomas. They are often located in the nasopharyngeal region associated with the pharyngeal pituitary. The location and pathologic features of these masses make them atypical when compared with intrasellar pituitary adenomas. A 54-year-old man presented with vertebral compression fracture and physical stigmata of Cushing’s disease. Biochemical testing confirmed hypercortisolemia responsive to high dose dexamethasone suppression. MRI of the head demonstrated an enhancing mass in the posterior aspect of the sphenoid sinus not involving the sella turcica. Endoscopic biopsy followed by resection confirmed this mass to be a pituitary adenoma with unusual pathologic features. Most notably, the tumor cells demonstrated large, eosinophilic, vacuolated cytoplasm. Immunohistochemical profile of the tumor was typical of an ACTH secreting tumor, notably with positivity for ACTH. The patient did well from his surgery. Post-operatively his serum cortisol level normalized and he remains in chemical remission one year after surgery. Ectopic pituitary adenomas are an unusual manifestation of hormonally active pituitary neoplastic disease. Their atypical clinical presentations, location, and pathologic features can make them a diagnostic challenge. Clinicians should be aware of these entities, especially when considering differential diagnosis for a mass in the sphenoid sinus and nasopharyngeal region

Assessment of burnout prevention and wellness programs for US-based neurosurgical faculty and residents: a systematic review of the literature

OBJECTIVE: Neurosurgeon burnout is a serious and prevalent issue that has been shown to impact professionalism, physician health, and patient outcomes. Interventions targeting physician burnout primarily focus on improving physician wellness. Many academic neurosurgery programs have established wellness curricula to combat burnout and improve wellness. No official recommendations exist for establishing a wellness program that effectively targets sources of burnout. The aim of this review was to examine measures of burnout and report objective results of wellness interventions for neurosurgical faculty and residents. METHODS: Two systematic literature reviews were performed in parallel, in accordance with PRISMA 2009 guidelines. Following removal of duplicates, a query of PubMed/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases yielded 134 resident-related articles and 208 faculty-related articles for abstract screening. After abstract screening, 17 articles with a primary focus of resident wellness and 10 with a focus on faculty wellness met criteria for full-text screening. Of the total 27 screened articles, 9 (6 resident, 2 faculty, 1 both resident and faculty) met criteria and were included in the final analysis. Article quality was assessed using the Joanna Briggs Institute critical appraisal tools for cohort studies. RESULTS: Included studies reported burnout rates for neurosurgery residents of 30%-67%. Work-life imbalance, imbalance of duties, inadequate operative exposure, and hostile faculty were contributors to burnout. The 2 included studies reported burnout rates for neurosurgery faculty members of 27% and 56.7%. Psychosocial stressors, relational stressors, and financial uncertainty were generally associated with increased feelings of burnout. Of the 4 studies reporting on outcomes of wellness initiatives included in this review, 3 reported a positive impact of the wellness interventions and 1 study reported no significant improvement after implementing a wellness initiative. CONCLUSIONS: Burnout among neurosurgical faculty and residents is prevalent and permeates the daily lives of neurosurgeons, negatively affecting patient outcomes, career satisfaction, and quality of life. Many neurosurgery programs have instituted wellness programs to combat burnout, but few have published evidence of improvement after implementation. While studies have shown that residents and faculty recognize the importance of wellness and look favorably on such initiatives, very few studies have reported objective outcomes

Assessment of burnout prevention and wellness programs for US-based neurosurgical faculty and residents: a systematic review of the literature

OBJECTIVE: Neurosurgeon burnout is a serious and prevalent issue that has been shown to impact professionalism, physician health, and patient outcomes. Interventions targeting physician burnout primarily focus on improving physician wellness. Many academic neurosurgery programs have established wellness curricula to combat burnout and improve wellness. No official recommendations exist for establishing a wellness program that effectively targets sources of burnout. The aim of this review was to examine measures of burnout and report objective results of wellness interventions for neurosurgical faculty and residents. METHODS: Two systematic literature reviews were performed in parallel, in accordance with PRISMA 2009 guidelines. Following removal of duplicates, a query of PubMed/MEDLINE, Scopus, Ovid, Cochrane, and EMBASE databases yielded 134 resident-related articles and 208 faculty-related articles for abstract screening. After abstract screening, 17 articles with a primary focus of resident wellness and 10 with a focus on faculty wellness met criteria for full-text screening. Of the total 27 screened articles, 9 (6 resident, 2 faculty, 1 both resident and faculty) met criteria and were included in the final analysis. Article quality was assessed using the Joanna Briggs Institute critical appraisal tools for cohort studies. RESULTS: Included studies reported burnout rates for neurosurgery residents of 30%-67%. Work-life imbalance, imbalance of duties, inadequate operative exposure, and hostile faculty were contributors to burnout. The 2 included studies reported burnout rates for neurosurgery faculty members of 27% and 56.7%. Psychosocial stressors, relational stressors, and financial uncertainty were generally associated with increased feelings of burnout. Of the 4 studies reporting on outcomes of wellness initiatives included in this review, 3 reported a positive impact of the wellness interventions and 1 study reported no significant improvement after implementing a wellness initiative. CONCLUSIONS: Burnout among neurosurgical faculty and residents is prevalent and permeates the daily lives of neurosurgeons, negatively affecting patient outcomes, career satisfaction, and quality of life. Many neurosurgery programs have instituted wellness programs to combat burnout, but few have published evidence of improvement after implementation. While studies have shown that residents and faculty recognize the importance of wellness and look favorably on such initiatives, very few studies have reported objective outcomes

Cushing-type ectopic pituitary adenoma with unusual pathologic features

Ectopic pituitary adenomas comprise, by varying reports, approximately 1-2% of all pituitary adenomas. They are often located in the nasopharyngeal region associated with the pharyngeal pituitary. The location and pathologic features of these masses make them atypical when compared with intrasellar pituitary adenomas. A 54-year-old man presented with vertebral compression fracture and physical stigmata of Cushing’s disease. Biochemical testing confirmed hypercortisolemia responsive to high dose dexamethasone suppression. MRI of the head demonstrated an enhancing mass in the posterior aspect of the sphenoid sinus not involving the sella turcica. Endoscopic biopsy followed by resection confirmed this mass to be a pituitary adenoma with unusual pathologic features. Most notably, the tumor cells demonstrated large, eosinophilic, vacuolated cytoplasm. Immunohistochemical profile of the tumor was typical of an ACTH secreting tumor, notably with positivity for ACTH. The patient did well from his surgery. Post-operatively his serum cortisol level normalized and he remains in chemical remission one year after surgery. Ectopic pituitary adenomas are an unusual manifestation of hormonally active pituitary neoplastic disease. Their atypical clinical presentations, location, and pathologic features can make them a diagnostic challenge. Clinicians should be aware of these entities, especially when considering differential diagnosis for a mass in the sphenoid sinus and nasopharyngeal region

Workplace Violence and Neurosurgery: Insights from a Nationwide Survey

OBJECTIVE: Workplace violence (WPV) against neurosurgeons is an understudied phenomenon, as previous research has focused on high-risk specialties like emergency medicine and psychiatry. We sought to fill in this gap in the literature by determining the frequency and type of WPV that neurosurgeons experience. METHODS: We sent a 26-question online survey to members of the American Association of Neurological Surgery via SurveyMonkey. This survey contained questions about WPV experienced over the previous two years, as well as questions about security measures and workplace protocols for WPV. RESULTS: We received 107 responses of 4757 surveys disseminated, a response rate of 2.25%. Although small, this response rate is representative of historical survey response rates. In total, 53.3% of our sample reported WPV, and 4.7% reported at least one physical assault. In total, 50.5% of respondents were afraid of becoming a victim of WPV, and 40.4% felt less secure today than when they began practicing. A total of 17.8% of respondents reported that they had obtained a weapon or a concealed weapon permit due to a perceived threat. Tests for association revealed that early career and female neurosurgeons were significantly more likely to receive verbal threats than other neurosurgeons (P = 0.049 and 0.01, respectively). CONCLUSIONS: WPV is prevalent in neurosurgery at rates comparable with a range of other specialties. Many neurosurgeons feel unsafe in the workplace, with some taking significant actions such as weapon acquisition. An opportunity for education and resources regarding WPV exists, especially among early career and female neurosurgeons

Neurosurgery perception of Enhanced Recovery After Surgery (ERAS) protocols

Enhanced Recovery After Surgery (ERAS) protocols are widespread in several fields, particularly general surgery, and attempt to deliver surgical care at a lower cost while also improving patient outcomes. However, few institutions have implemented ERAS protocols in neurosurgery. As such, a survey of neurosurgeons on the current state of ERAS in neurosurgery was conducted to provide insight on scaling the practice nationally. A 15-question survey was designed to assess the implementation of andsatisfaction with ERAS protocols at individual institutions. A total of 39 responses were collected from 38 unique institutions. 58.9%(N = 23) reported implementation of neurosurgical ERAS protocols. 52.1% (N = 12) of the responses were neurosurgeons at academic institutions withneurosurgical residency programs. Most neurosurgeons used ERAS protocolsfor spine cases (N = 23), with only 17.3% (N = 4) employing ERAS protocolsfor cranial cases. 69.5% (N = 16) of survey participants reported that thedesign and implementation of ERAS was a multidisciplinary effort acrossmany departments, including neurosurgery, anesthesia, and pharmacy.Decreased costs and intensive care unit (ICU) admission were reported tobe unanticipated benefits of ERAS implementation. Unanticipated challenges to implementation of new protocols included difficulties withelectronic medical record (EMR) integration, agreement of protocoldetails amongst stakeholders, uniform implementation of protocols by allneurosurgeons, and lack of adaptability by multidisciplinary staff. Meandepartment satisfaction with ERAS protocol implementation was 4.00 +/- 0.81 (N = 22) on a 5-point Likert scale