Driving Quality Improvement through the Morbidity and Mortality Conference Portal

Historically, morbidity and mortality conferences in surgical disciplines have been used for blaming, shaming, and explaining. Transparency was not a feature. The Department of Neurosurgery at Thomas Jefferson University Hospital decided to reconfigure their M&M conferences so that they could be used as an opportunity to focus on reporting and evidence-based medicine, and lead to quality improvement projects in the department and the neuroscience hospital. Join Dr. Ashwini Sharon to hear how that was accomplished

Variability of patient spine education by Internet search engine.

BACKGROUND: Patients are increasingly reliant upon the Internet as a primary source of medical information. The educational experience varies by search engine, search term, and changes daily. There are no tools for critical evaluation of spinal surgery websites. PURPOSE: To highlight the variability between common search engines for the same search terms. To detect bias, by prevalence of specific kinds of websites for certain spinal disorders. Demonstrate a simple scoring system of spinal disorder website for patient use, to maximize the quality of information exposed to the patient. STUDY DESIGN: Ten common search terms were used to query three of the most common search engines. The top fifty results of each query were tabulated. A negative binomial regression was performed to highlight the variation across each search engine. RESULTS: Google was more likely than Bing and Yahoo search engines to return hospital ads (P=0.002) and more likely to return scholarly sites of peer-reviewed lite (P=0.003). Educational web sites, surgical group sites, and online web communities had a significantly higher likelihood of returning on any search, regardless of search engine, or search string (P=0.007). Likewise, professional websites, including hospital run, industry sponsored, legal, and peer-reviewed web pages were less likely to be found on a search overall, regardless of engine and search string (P=0.078). CONCLUSION: The Internet is a rapidly growing body of medical information which can serve as a useful tool for patient education. High quality information is readily available, provided that the patient uses a consistent, focused metric for evaluating online spine surgery information, as there is a clear variability in the way search engines present information to the patient

Neurosurgical Applications of Magnetic Resonance Diffusion Tensor Imaging

Magnetic Resonance (MR) Diffusion Tensor Imaging (DTI) is a rapidly evolving technology that enables the visualization of neural fiber bundles, or white matter (WM) tracts. There are numerous neurosurgical applications for MR DTI including: (1) Tumor grading and staging; (2) Pre-surgical planning (determination of resectability, determination of surgical approach, identification of WM tracts at risk); (3) Intraoperative navigation (tumor resection that spares WM damage, epilepsy resection that spares WM damage, accurate location of deep brain stimulation structures); (4) Post-operative assessment and monitoring (identification of WM damage, identification of tumor recurrence). Limitations of MR DTI include difficulty tracking small and crossing WM tracts, lack of standardized data acquisition and post-processing techniques, and practical equipment, software, and timing considerations. Overall, MR DTI is a useful tool for planning, performing, and following neurosurgical procedures, and has the potential to significantly improve patient care. Technological improvements and increased familiarity with DTI among clinicians are next steps

Case Report: Hemorrhage into an Occult Spinal Ependymoma after Epidural Anesthesia

Epidural anesthesia is a procedure which is well tolerated and has a low incidence of adverse events. In performing caesarean sections, regional anesthesia (spinal or epidural) is the preferred modality for anesthetic delivery. Although rare with continuous epidural anesthesia, epidural hematomas have been reported to occur with an incidence between 1:150,000 and 1:190,00010. An underlying bleeding diathesis has been implicated as a causative factor. We present the sixth reported case of hemorrhage into an occult intradural neoplasm after spinal or epidural anesthesia. Similar lesions have not been reported in the recent spine literature

Improving the Virtual Neurosurgery Residency Interview Experience

The residency selection process has proven a challenge in the face of the Covid-19 pandemic. In the neurosurgery match, residents are chosen based on objective metrics as well as their ability to effectively work as part of a team tasked with caring for medically complex patients faced with neurosurgical conditions. As there remain limitations on the number of externships students could participate in and the Step 1 examination is expected to be reported as either pass or fail in years to come, we will have fewer objective metrics to review in the student application. We conducted a study to best select neurosurgery resident applicants who could effectively work with our team to ultimately provide effective patientcentered care. Through a post-interview survey among applicants, we identified points of improvements for the neurosurgery residency application interview

Standardizing Postoperative Handoffs Using the Evidence-Based IPASS Framework Improves Handoff Communication for Postoperative Neurosurgical Patients in the Neuro-Intensive Care Unit

Aims for Improvement Within one year of initiation of the process improvement plan, we wanted to improve: Direct communication of airway and hemodynamic concerns Direct communication of operative events, complications, and perioperative management goals. Attendance at postoperative handoffs Confirmation of information by receiving teams Staff perceptions of handoff efficacy and teamwork

Intraoperative Vancomycin Use in Spinal Surgery: Single Institution Experience and Microbial Trends.

Study Design. Retrospective Case Series.Objective. To demonstrate the microbial trends of spinal surgical site infections(SSI) in patients who had previously received crystallized vancomycin in the operative bed.Summary of Background Data. Prior large, case control series demonstrate the significant decrease in SSI with the administration of vancomycin in the wound bed.Methods. A single institution, electronic database search was conducted for all spinal surgery patients who had received prophylactic crystalline vancomycin powder in the wound bed. Patient\u27s with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excludedResults. 981 consecutive patients (494 male, 487 female, mean age 59.4 years, range 16-95 years) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 grams(range: 1-6 grams). 66 patients (6.71%) were diagnosed with a SSI of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 grams in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 grams in 23 cases where a gram negative infection was cultured. 15 of the 51 (29.4%) positive-cultures were polymicrobial. 8 (53%) of these 15 polymicrobial cultures contained three or more distinct organisms.Conclusion. Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of non-positive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship

Deep Brain Stimulation: Awake and Asleep Options

A BRIEF HISTORY OF DBS AND NEUROIMAGING Stereotactic neurosurgery is founded on the ability to accurately localize and safely access targets within the brain in a minimally-invasive manner. The stereotactic method was first described in 1908 by Sir Victor Horsley and Robert Clarke at University College London, where they developed an apparatus for animal experimentation that allowed them to establish a threedimensional Cartesian coordinate system for targeting. At that time, however, x-rays were the only available form of imaging the human body and as such, localizing intracranial targets relied on a combination of knowledge from anatomical atlases and the visualization of a few intracranial landmarks such as the pineal gland or the foramen of Monroe. These landmarks could be visualized by filling the ventricles with air (pneumoencephalogram) or a contrast medium (ventriculogram) [Figure 1]. In 1947, Ernst Spiegel and Henry Wycis created the first human stereotactic frame that allowed for lesioning of deep brain nuclei for the treatment of psychiatric disease.2 With imaging limited to x-rays alone, a need arose for another means of confirming the appropriate location where a lesion would be made or an electrode would be implanted. Nicholas Wetzel and Ray S. Snider have been accredited with performing the first microelectrode recording (MER) in humans in 1958 during a pallidotomy.3 Over time, particularly with the popularization of thalamotomy for the treatment of Parkinson’s disease and with a growing appreciation of characteristic recordings of specific nuclei, MER became commonplace in stereotactic neurosurgery. Pages: 2-8