Impact of resident involvement in neurosurgery: an analysis of 8748 patients from the 2011 American College of Surgeons National Surgical Quality Improvement Program database

Operating room organization and surgical performance: a systematic review

BACKGROUND

Organizational factors may influence surgical outcomes, regardless of extensively studied factors such as patient preoperative risk and surgical complexity. This study was designed to explore how operating room organization determines surgical performance and to identify gaps in the literature that necessitate further investigation.

METHODS

We conducted a systematic review according to PRISMA guidelines to identify original studies in Pubmed and Scopus from January 1, 2000 to December 31, 2019. Studies evaluating the association between five determinants (team composition, stability, teamwork, work scheduling, disturbing elements) and three outcomes (operative time, patient safety, costs) were included. Methodology was assessed based on criteria such as multicentric investigation, accurate population description, and study design.

RESULTS

Out of 2625 studies, 76 met inclusion criteria. Of these, 34 (44.7%) investigated surgical team composition, 15 (19.7%) team stability, 11 (14.5%) teamwork, 9 (11.8%) scheduling, and 7 (9.2%) examined the occurrence of disturbing elements in the operating room. The participation of surgical residents appeared to impact patient outcomes. Employing specialized and stable teams in dedicated operating rooms showed improvements in outcomes. Optimization of teamwork reduced operative time, while poor teamwork increased morbidity and costs. Disturbances and communication failures in the operating room negatively affected operative time and surgical safety.

CONCLUSION

While limited, existing scientific evidence suggests that operating room staffing and environment significantly influences patient outcomes. Prioritizing further research on these organizational drivers is key to enhancing surgical performance.

Learning Effect for Large Joint Diagnostic Aspirations With Fluoroscopy and Ultrasound

OBJECTIVE

The first objective was to identify whether increased experience, gauged by number of procedures performed posttraining, is correlated with greater likelihood of obtaining joint fluid in diagnostic aspirations. The second objective was to identify whether trainee involvement at the time of procedure affected the success rate of the procedure (which in this case was obtaining fluid on aspiration).

DESIGN

This was a retrospective analysis of fluoroscopic- and ultrasound-guided large joint aspirations. Logarithmic fit was performed to identify the presence of a learning curve to the successful attainment of fluid with experience. Logistic regression analysis was used to identify whether trainee presence for a procedure affected fluid attainment.

RESULTS

Ultrasound did not demonstrate a significant fit to the logarithmic curve ( P = 0.447), whereas fluoroscopy did ( P < 0.001), indicative of a learning curve for fluoroscopy. After adjusting for covariates, joint fluid was successfully attained at a similar rate whether trainees were present or not. Significant independent factors related to successful joint fluid attainment were image guidance technique ( P = 0.001), body mass index ( P = 0.032), and joint aspirated (overall P < 0.001).

CONCLUSION

There was a statistically significant learning curve for fluoroscopic-guided joint aspirations, but not with ultrasound guidance. Trainee involvement did not affect the success rate of joint aspirations.

Neurosurgery outcomes and complications in a monocentric 7-year patient registry

Introduction

Capturing adverse events reliably is paramount for clinical practice and research alike. In the era of “big data”, prospective registries form the basis of clinical research and quality improvement.

Research question

To present results of long-term implementation of a prospective patient registry, and evaluate the validity of the Clavien-Dindo grade (CDG) to classify complications in neurosurgery.

Materials and methods

A prospective registry for cranial and spinal neurosurgical procedures was implemented in 2013. The CDG – a complication grading focused on need for unplanned therapeutic intervention – was used to grade complications. We assess construct validity of the CDG.

Results

Data acquisition integrated into our hospital workflow permitted to include all eligible patients into the registry. We have registered 8226 patients that were treated in 11994 surgeries and 32494 consultations up until December 2020. Similarly, we have captured 1245 complications on 6308 patient discharge forms (20%) since full operational status of the registry. The majority of complications (819/6308 ​= ​13%) were treated without invasive treatment (CDG 1 or CDG 2). At discharge, there was a clear correlation of CDG and the Karnofsky Performance Status (KPS, rho ​= ​-0.29, slope -7 KPS percentage points per increment of CDG) and the length of stay (rho ​= ​0.43, slope 3.2 days per increment of CDG).

Discussion and conclusion

Patient registries with high completeness and objective capturing of complications are central to the process of quality improvement. The CDG demonstrates construct validity as a measure of complication classification in a neurosurgical patient population.

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A prospective registry for cranial and spinal neurosurgical procedures was implemented in 2013.

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We have registered 8226 patients that were treated in 11994 surgeries and 32494 consultations up until December 2020.

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There was a clear correlation of CDG with the Karnofsky Performance Status and with length of hospital stay.

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The Clavien-Dindo grading (CDG) demonstrates construct validity as a measure of complication severity in a neurosurgical patient population.

Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures

OBJECTIVE

Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery.

METHODS

In November 2013, a preoperative CHG shower protocol was implemented at the authors' institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates.

RESULTS

The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67-13.1; p = 0.15).

CONCLUSIONS

This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.

Overlapping single-level lumbar fusion and adverse short-term outcomes

OBJECTIVE

There is a paucity of research on the safety of overlapping surgery. The purpose of this study was to evaluate the impact of overlapping surgery on a homogenous population of exactly matched patients undergoing single-level, posterior-only lumbar fusion.

METHODS

The authors retrospectively analyzed case data of 3799 consecutive adult patients who underwent single-level, posterior-only lumbar fusion during a 6-year period (June 7, 2013, to April 29, 2019) at a multihospital university health system. Outcomes included 30-day emergency department (ED) visit, readmission, reoperation, and morbidity and mortality following surgery. Thereafter, coarsened exact matching was used to match patients with and without overlap on key demographic factors, including American Society of Anesthesiologists (ASA) class, Charlson Comorbidity Index (CCI) score, sex, and body mass index (BMI), among others. Patients were subsequently matched by both demographic data and by the specific surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographically matched cohort, and the surgeon-matched cohort, with significance set at a p value < 0.05.

RESULTS

There was no significant difference in morbidity or any short-term outcome, including readmission, reoperation, ED evaluation, and mortality. Among the demographically matched cohort and surgeon-matched cohort, there was no significant difference in age, sex, history of prior surgery, ASA class, or CCI score. Overlapping surgery patients in both the demographically matched cohort and the matched cohort limited by surgeon had longer durations of surgery (p < 0.01), but no increased morbidity or mortality was noted. Patients selected for overlap had fewer prior surgeries and lower ASA class and CCI score (p < 0.01). Patients with overlap also had a longer duration of surgery (p < 0.01) but not duration of closure.

CONCLUSIONS

Exactly matched patients undergoing overlapping single-level lumbar fusion procedures had no increased short-term morbidity or mortality; however, duration of surgery was 20 minutes longer on average for overlapping operations. Further studies should assess long-term patient outcomes and the impact of overlap in this and other surgical procedures.

Assessing the Impact of Urology Resident Involvement on Overall Patient Satisfaction

INTRODUCTION

To assess the impact of resident participation on patient satisfaction by comparing post-discharge satisfaction scores between academic faculty, private urologists who work with residents, and private urologists with no involvement in resident education.

METHODS

Post-discharge Hospital Consumer Assessment of Healthcare Providers and Systems surveys from academic and private urologists at a single institution with an accredited Urology residency program from January 1, 2014 to December 31, 2016 (n = 530) were reviewed. The surveys were de-identified and categorized based on 3 subgroups of providers: academic faculty, private with residents, and private without residents. Overall rating, physician (MD) communication, nursing (RN) communication, discharge information, and overall management during their hospitalization were assessed.

RESULTS

The faculty group received an overall patient satisfaction score of 88.3% (percentage of 9 or 10). The private with resident group had an overall satisfaction score of 92.0% and the private without resident group had an overall satisfaction score of 96.7%. There was no statistical difference in patient satisfaction scores between groups across all categories with the exception of MD and RN communication. Private urologists with residents had better MD and RN communication scores than the 2 other groups (p < 0.001, p = 0.013, respectively).

CONCLUSIONS

Resident involvement in patient care with faculty or private attendings did not have a negative effect on patient satisfaction scores of any factor measured. Patients were more satisfied with MD and RN communication when residents worked with private attendings.

The economic value of an on-call neurosurgical resident physician

OBJECTIVE

The cost of training neurosurgical residents is especially high considering the duration of training and the technical nature of the specialty. Despite these costs, on-call residents are a source of significant economic value, through both indirectly and directly supervised activities. The authors sought to identify the economic value of on-call services provided by neurosurgical residents.

METHODS

A personal call log kept by a single junior neurosurgical resident over a 2-year period was used to obtain the total number of consultations, admissions, and procedures. Current Procedural Terminology (CPT) codes were used to estimate the resident's on-call economic value.

RESULTS

A single on-call neurosurgical resident at the authors' institution produced 8172 work relative value units (wRVUs) over the study period from indirectly and directly supervised activities. Indirectly supervised procedures produced 7052 wRVUs, and directly supervised activities using the CPT modifier 80 yielded an additional 1120 wRVUs. Using the assistant surgeon billing rate for directly supervised activities and the Medical Group Management Association nationwide median neurosurgery reimbursement rate, the on-call activities of a single resident generated a theoretical billing value of $689,514 over the 2-year period, or $344,757 annually. As a program, the on-call residents collectively produced 39,550 wRVUs over the study period, or 19,775 wRVUs annually, which equates to potential reimbursements of $1,668,386 annually.

CONCLUSIONS

Neurosurgery residents at the authors' institution theoretically produce enough economic value exclusively from on-call activities to far exceed the cost of their education. This information could be used to more precisely estimate the true overall cost of neurosurgical training and determine future graduate medical education funding.

Evidence-based practice of stereotactic radiosurgery: Outcomes from an educational course for neurosurgery and radiation oncology residents

Background:

As the field of brain and spine stereotactic radiosurgery (SRS) continues to grow, so will the need for a comprehensive evidence base. However, it is unclear to what degree trainees feel properly equipped to use SRS. We assess the perceptions and comfort level reported by neurosurgery and radiation oncology residents concerning the evidence-based practice of SRS.

Methods:

A continuing medical education (CME) course provided peer-reviewed updates regarding treatment with intracranial and spinal SRS. Presentations were given by neurosurgery and radiation oncology residents with mentorship by senior faculty. To gauge perceptions regarding SRS, attendees were surveyed. Responses before and after the course were analyzed using the Fisher’s exact test in R statistical software.

Results:

Participants reported the greatest knowledge improvements concerning data registries (P < 0.001) and clinical trials (P = 0.026). About 82% of all (n = 17) radiation oncology and neurosurgery residents either agreed or strongly agreed that a brain and spine SRS rotation would be beneficial in their training. However, only 47% agreed or strongly agreed that one was currently part of their training. In addition, knowledge gains in SRS indications (P = 0.084) and ability to seek collaboration with colleagues (P = 0.084) showed notable trends.

Conclusion:

There are clear knowledge gaps shared by potential future practitioners of SRS. Specifically, knowledge regarding SRS data registries, indications, and clinical trials offer potential areas for increased educational focus. Furthermore, the gap between enthusiasm for increased SRS training and the current availability of such training at medical institutions must be addressed.

Incidence and risk factors of early postoperative complications in patients after decompressive craniectomy: a 5-year experience

PURPOSE

Decompressive craniectomy is an effective measure to reduce a pathologically elevated intracranial pressure. Patients' survival and life quality following this surgery have been a subject of several studies and significantly differ according to the primary diagnosis. Since this operation is often associated with a wide spectrum of possibly serious complications, we aimed to describe their incidence and possible associated risk factors.

METHODS

We evaluated 118 patients who underwent decompressive craniectomy at our clinic during years 2013-2017. The indications included traumatic brain injuries, ischaemic or haemorrhagic strokes and postoperative complications of planned neurosurgical procedures. Subsequently, we assessed the incidence of early postoperative complications (occurring during the first 3 postoperative weeks). The results were statistically analysed with relation to a wide selection of possible risk factors.

RESULTS

At least one early surgical postoperative complication occurred in 87 (73.73%) patients, the most frequent being a development of an extraaxial fluid collection in 41 (34.75%) patients. We were able to identify risk factors linked with extraaxial fluid collections, subcutaneous and extradural haematomas, postoperative seizures and meningitis. An overall need for reoperation was 13.56%. Neither the duration of the surgery nor the qualification of the operating surgeon had any effect on the complications' occurrence.

CONCLUSIONS

Decompressive craniectomy is associated with numerous early postoperative complications with a various degree of severity. Most cases of complications can, however, be managed in a conservative way. The risk factors linked with postoperative complications should be taken into account during the indication process in each individual patient.

Effect of an additional neurosurgical resident on procedure length, operating room time, estimated blood loss, and post-operative length-of-stay

Introduction: Neurosurgical residency training is costly, with expenses largely borne by the academic institutions that train residents. One expense is increased operative duration, which leads to poorer patient outcomes. Although other studies have assessed the effect of one resident assisting, none have investigated two residents; thus, we sought to investigate if two residents versus one scrubbed-in impacted operative time, estimated blood loss (EBL), and length-of-stay (LOS).Methods: In this retrospective review of patients who underwent a neurosurgical procedure involving one or two residents between January 2013 and April 2016, we performed multivariable linear regression to determine if there was an association between resident participation and case length, operating room time, EBL, and LOS. We also included patient demographics, attending surgeon, day of the week, start time, pre-operative LOS, procedure performed, and other variables in our model. Only procedures performed at least 40 times during the study period were analyzed.Results: Of 860 procedures that met study criteria, 492 operations were one of six procedures performed at least 40 times, which were anterior cervical discectomy and fusion, cerebrospinal fluid (CSF) shunt insertion, CSF shunt revision, lumbar laminectomy, intracranial hematoma evacuation, and non-skull base, supratentorial parenchymal brain tumor resection. An additional resident was associated with a 35.1-min decrease (p = .01) in operative duration for lumbar laminectomies. However, for intracranial hematoma evacuations, an extra resident was associated with a 24.1 min increase (p = .03) in procedural length. There were no significant differences observed in the other four surgeries.Conclusion: An additional resident may lengthen duration of intracranial hematoma evacuations. However, two residents scrubbed-in were associated with decreased lumbar laminectomy duration. Overall, an extra resident does not increase procedural duration, total operating room utilization, EBL, or post-operative LOS. Allowing two residents to scrub in may be a safe and cost-effective method of educating neurosurgical residents.

Reporting Methodology of Neurosurgical Studies Utilizing the American College of Surgeons-National Surgical Quality Improvement Program Database: A Systematic Review and Critical Appraisal

BACKGROUND

Use of large databases such as the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has become increasingly common in neurosurgical research.

OBJECTIVE

To perform a critical appraisal and evaluation of the methodological reporting for studies in neurosurgical literature that utilize the ACS-NSQIP database.

METHODS

We queried Ovid MEDLINE, EMBASE, and PubMed databases for all neurosurgical studies utilizing the ACS-NSQIP. We assessed each study according to number of criteria fulfilled with respect to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) Statement, and Journal of American Medical Association–Surgical Section (JAMA-Surgery) Checklist. A separate analysis was conducted among papers published in core and noncore journals in neurosurgery according to Bradford's law.

RESULTS

A total of 117 studies were included. Median (interquartile range [IQR]) scores for number of fulfilled criteria for STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist were 20 (IQR:19-21), 9 (IQR:8-9), and 6 (IQR:5-6), respectively. For STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist, item 9 (potential sources of bias), item 13 (supplemental information), and item 9 (missing data/sensitivity analysis) had the highest number of studies with no fulfillment among all studies (56, 68, 50%), respectively. When comparing core journals vs noncore journals, no significant difference was found (STROBE, P = .94; RECORD, P = .24; JAMA-Surgery checklist, P = .60).

CONCLUSION

While we observed an overall satisfactory reporting of methodology, most studies lacked mention of potential sources of bias, data cleaning methods, supplemental information, and external validity. Given the pervasive role of national databases and registries for research and health care policy, the surgical community needs to ensure the credibility and quality of such studies that ultimately aim to improve the value of surgical care delivery to patients.

Resident Impact on Patient & Surgeon Satisfaction and Outcomes: Evidence for Health System Support for Urology Education

OBJECTIVE

To assess the effect of resident involvement on patient and physician satisfaction, we evaluated the outcomes from a private urology group both prior to and after initiation of resident coverage.

METHODS

Urologic procedures completed by attending surgeons without residents from October 2010 to December 2011 were compared to the same surgeons working with residents from January 2012 to March 2013. Surgical case times, postoperative complications, readmission rate, length of stay, Press-Ganey consumer assessments, resident and physician self-report of training quality and quality of life were collected.

RESULTS

3316 operative and nonoperative cases were measured.Total 1565 were in preresident periods and 1751 were in postresident periods. With resident coverage, there was an increase in OR times. There was no difference in complications for surgical and nonsurgical cases (P = .2269 and P = 1.000, respectively). There was a statistically significant improvement of readmission rate in nonsurgical patients with resident coverage (P = .0344). Patients' satisfaction scores were higher in every category and they more often reported that they "always" received quality care (78.6 % vs 82.5%) with resident coverage. Resident and faculty perceptions of training, patient care, and satisfaction increased with resident coverage.

CONCLUSION

Resident coverage of a private practice urology group resulted in no difference in surgical complications and improvement in readmission rates in nonsurgical patients. It resulted in longer OR times but greater satisfaction of faculty, residents and most important, patients. Our data demonstrate the beneficial effect of resident participation in patient care and provides further justification of residency financial support.

Adverse Events After Microvascular Decompression: A National Surgical Quality Improvement Program Analysis

BACKGROUND

Although microvascular decompression (MVD) is a durable treatment for medically refractory trigeminal neuralgia, hemifacial spasm, or glossopharyngeal neuralgia attributable to neurovascular conflict, few national studies have analyzed predictors of postoperative complications.

OBJECTIVE

To determine the incidence and risk factors for adverse events after MVD.

METHODS

Patients who underwent MVD were extracted from the prospectively collected National Surgical Quality Improvement Program registry (2006-2017). Multivariable logistic regression identified predictors of 30-day adverse events and unplanned readmission; multivariable linear regression analyzed predictors of a longer hospital stay.

RESULTS

Among the 1005 patients evaluated, the mortality was 0.3%, major neurologic complication rate 0.4%, and 2.8% had a nonroutine hospital discharge. Patient age was not a predictor of any adverse events. Statistically significant independent predictors both of any adverse event (9.2%) and of a longer hospitalization were American Society of Anesthesiologists (ASA) classification III-IV designation and longer operative duration (P ≤ 0.03) The 30-day readmission rate was 6.8%, and the most common reasons were surgical site infections (22.4%) and cerebrospinal fluid leakage (14.3%). Higher ASA classification, diabetes mellitus, and operative time were predictors of readmission (P < 0.04).

CONCLUSIONS

In this National Surgical Quality Improvement Program analysis, postoperative morbidity and mortality after MVD was low. Patient age was not a predictor of postoperative complications, whereas higher ASA classification, diabetes mellitus, and longer operative duration were predictive of any adverse event and readmission. ASA classification provided superior risk stratification compared with the total number of patient comorbidities or laboratory values. These data can assist with preoperative patient counseling and risk stratification.

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Postoperative Outcomes

BACKGROUND

Previous studies have failed to demonstrate statistically significant differences in postsurgical outcomes between operative cases featuring resident participation compared to attending only; however, the effects of level of postgraduate year (PGY) training have not been explored.

OBJECTIVE

To correlate different PGYs in neurosurgery with 30-d postoperative outcomes.

METHODS

Using National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open-vascular, cranial, and functional in teaching institutions. Comparison groups: cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Primary outcome measures included any wound disruption (surgical site infections and/or wound dehiscence), Clavien-Dindo grade IV (life-threatening) complications, and death.

RESULTS

Compared to junior residents (n = 3729) and mid-level residents (n = 2779), senior residents (n = 3692) operated on patients with a greater comorbidity burden, as reflected by higher American Society of Anesthesiology classifications and decreased level of functional status. Cases with senior resident participation experienced the highest percentages of postoperative wound complications (P = .005), Clavien-Dindo grade IV complications (P = .001), and death (P = .035). However, following multivariable regression, level of residency training in neurosurgery did not predict any of the 3 primary outcome measures. Compared to spinal cases, cranial cases predicted a higher incidence of life-threatening complications (odds ratio 1.84, P < .001).

CONCLUSION

Cases in the senior resident cohort were more technically challenging and exhibited a higher comorbidity burden preoperatively; however, level of neurosurgical training did not predict any wound disruption, life-threatening complications, or death. Residents still provide safe and effective assistance to attending neurosurgeons.

A nationwide analysis of 30-day adverse events, unplanned readmission, and length of hospital stay after peripheral nerve surgery in extremities and the brachial plexus

Background

Little is known on adverse events and their timing after peripheral nerve surgery in extremities. The aim of this study is to identify predictors and typical timing of complications, unplanned readmission, and length of hospital stay for patients undergoing peripheral nerve surgery in the extremities.

Methods

Data were extracted from the National Surgical Quality Improvement Program (NSQIP) registry from 2005 to 2015. Adult patients undergoing peripheral nerve surgery in the extremities were included. A subgroup analysis was performed for brachial plexus operations. Multivariable logistic regression was performed to identify predictors of any complication, surgical site infection, unplanned readmission, and reoperation.

Results

A total of 2,840 patients were identified; 628 were brachial plexus operations. Overall complications were 4.4% and 7.0%, respectively. Median time for occurrence of any complication was 8 days. The most common complications were wound‐related (1.7%), which occurred at a median of 15 days postoperatively. Reoperation occurred in 1.8% of all cases; most commonly for musculoskeletal repair (16.7%). Unplanned readmissions occurred in 2.3% and were most often due to wound‐related problems (24.1%). Preoperatively contaminated wounds, inpatient procedures, and longer operative time seemed to have the most influence on all adverse events. In brachial plexus pathology, insulin‐dependent diabetes and emergency cases also negatively affected outcomes.

Conclusions

Complications usually occur one to two weeks postoperatively. Preoperatively contaminated wounds, inpatient procedures, and longer operative times influence outcome. Anatomical level of operation results in significantly different lengths of hospital stay; brachial plexus pathology has the longest length of stay.

Impact of Resident Involvement in Neurosurgery: An American College of Surgeons' National Surgical Quality Improvement Program Database Analysis of 33,977 Patients

OBJECTIVE

There is conflicting and limited literature on the effect of intraoperative resident involvement on surgical outcomes. Our study assessed effects of resident involvement on outcomes in patients undergoing neurosurgery.

METHODS

We identified 33,977 adult neurosurgical cases from 374 hospitals in the 2006-2012 National Surgical Quality Improvement Program, a prospectively collected national database with established reproducibility and validity. Outcomes were compared according to resident involvement before and after 1:1 matching on procedure and perioperative risk factors.

RESULTS

Resident involvement was documented in 13,654 cases. We matched 10,170 resident-involved cases with 10,170 attending-alone. In the matched sample, resident involvement was associated with increased surgery duration (average, 34 minutes) and slight increases in odds for prolonged hospital stay (odds ratio, 1.2; 95% confidence interval [CI], 1.2-1.3) and complications (odds ratio, 1.2; 95% CI, 1.1-1.3) including infections (odds ratio, 1.4; 95% CI, 1.2-1.7). Increased risk for infections persisted after controlling for surgery duration (odds ratio, 1.3; 95% CI, 1.1-1.5). The majority of cases were spine surgeries, and resident involvement was not associated with morbidity or mortality for malignant tumor and aneurysm patients. Training level of residents was not associated with differences in outcomes.

CONCLUSION

Resident involvement was more common in sicker patients undergoing complex procedures, consistent with academic centers undertaking more complex cases. After controlling for patient and intraoperative characteristics, resident involvement in neurosurgical cases continued to be associated with longer surgical duration and slightly higher infection rates. Longer surgery duration did not account for differences in infection rates.

The Impact of Different Postgraduate Year Training in Neurosurgery Residency on 30-Day Return to Operating Room: A National Surgical Quality Improvement Program Study

OBJECTIVE

Because of the health care initiative on quality improvement projects in academic medicine, this study explores the impact of different postgraduate years (PGYs) on unexpected re-operation rates.

METHODS

Using the National Surgical Quality Improvement Program 2005-2014, adult neurosurgical cases were divided into subspecialties: spine, open vascular, cranial, and functional. Comparison groups were cases involving junior residents (PGY 1-PGY 3), mid-level residents (PGY 4 + PGY 5), and senior residents (PGY 6 + PGY 7). Comorbidity disease burden was measured by frailty index. The primary outcome measure was 30-day unintended return to the operating room.

RESULTS

Of the 9782 cases, re-operations were higher for those cases featuring a senior resident (5.6%) compared with mid-level resident (4.1%) and junior resident (3.8%) (P = 0.001). Although senior residents operated on patients with a statistically significantly higher neurologic disease burden, greater relative value units, longer operative times, and more 30-day postoperative adverse events, the level of resident training did not have an impact on revision surgery after multivariable logistical regression. The strongest predictors of return to the operating room included the frailty index (adjusted odds ratio [OR_adj] = 5.18, P < 0.001), functional subspecialty (OR_adj = 2.65, P < 0.001), and Wound Class 4 - dirty/infected wound (OR_adj = 2.33, P = 0.016).

CONCLUSIONS

Resident participation in neurosurgical cases does not affect 30-day unplanned re-operation rates, which were affected by frailty index, functional subspecialty, and wound class.

Venous thromboembolism and intracranial hemorrhage after craniotomy for primary malignant brain tumors: a National Surgical Quality Improvement Program analysis

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), frequently complicates the postoperative course of primary malignant brain tumor patients. Thromboprophylactic anticoagulation is commonly used to prevent VTE at the risk of intracranial hemorrhage (ICH). We extracted all patients who underwent craniotomy for a primary malignant brain tumor from the National Surgical Quality Improvement Program (NSQIP) registry (2005-2015) to perform a time-to-event analysis and identify relevant predictors of DVT, PE, and ICH within 30 days after surgery. Among the 7376 identified patients, the complication rates were 2.6, 1.5, and 1.3% for DVT, PE, and ICH, respectively. VTE was the second-most common major complication and third-most common reason for readmission. ICH was the most common reason for reoperation. The increased risk of VTE extends beyond the period of hospitalization, especially for PE, whereas ICH occurred predominantly within the first days after surgery. Older age and higher BMI were overall predictors of VTE. Dependent functional status and longer operative times were predictive for VTE during hospitalization, but not for post-discharge events. Admission two or more days before surgery was predictive for DVT, but not for PE. Preoperative steroid usage and male gender were predictive for post-discharge DVT and PE, respectively. ICH was associated with various comorbidities and longer operative times. This multicenter study demonstrates distinct critical time periods for the development of thrombotic and hemorrhagic events after craniotomy. Furthermore, the VTE risk profile depends on the type of VTE (DVT vs. PE) and clinical setting (hospitalized vs. post-discharge patients).

Cranial Tumor Surgical Outcomes at a High-Volume Academic Referral Center

OBJECTIVE

To determine adverse event rates for adult cranial neuro-oncologic surgeries performed at a high-volume quaternary academic center and assess the impact of resident participation on perioperative complication rates.

PATIENTS AND METHODS

All adult patients undergoing neurosurgical intervention for an intracranial neoplastic lesion between January 1, 2009, and December 31, 2013, were included. Cases were categorized as biopsy, extra-axial/skull base, intra-axial, or transsphenoidal. Complications were categorized as neurologic, medical, wound, mortality, or none and compared for patients managed by a chief resident vs a consultant neurosurgeon.

RESULTS

A total of 6277 neurosurgical procedures for intracranial neoplasms were performed. After excluding radiosurgical procedures and pediatric patients, 4151 adult patients who underwent 4423 procedures were available for analysis. Complications were infrequent, with overall rates of 9.8% (435 of 4423 procedures), 1.7% (73 of 4423), and 1.4% (63 of 4423) for neurologic, medical, and wound complications, respectively. The rate of perioperative mortality was 0.3% (14 of 4423 procedures). Case performance and management by a chief resident did not negatively impact outcome.

CONCLUSION

In our large-volume brain tumor practice, rates of complications were low, and management of cases by chief residents in a semiautonomous manner did not negatively impact surgical outcomes.

Hemorrhage associated with ventriculoperitoneal shunt placement in aneurysmal subarachnoid hemorrhage patients on a regimen of dual antiplatelet therapy: a retrospective analysis

OBJECTIVE

Intracranial stenting and flow diversion require the use of dual antiplatelet therapy (DAPT) to prevent in-stent thrombosis. DAPT may significantly increase the risk of hemorrhagic complications in patients who require subsequent surgical interventions. In this study, the authors sought to investigate whether DAPT is a risk factor for hemorrhagic complications associated with ventriculoperitoneal (VP) shunt placement in patients with aneurysmal subarachnoid hemorrhage (aSAH). Moreover, the authors sought to compare VP shunt complication rates with respect to the shunt's location from the initial external ventricular drain (EVD) site.

METHODS

Patients with aSAH who presented to the authors' institution from July 2009 through November 2016 and required VP shunt placement for persistent hydrocephalus were included. The rates of hemorrhagic complications associated with VP shunt placement were compared between patients who were on a regimen of DAPT (aspirin and clopidogrel) for use of a stent or flow diverter, and patients who underwent microsurgical clipping or coiling only and were not on DAPT using a backward stepwise multivariate analysis. Rates of radiographic hemorrhage and infection-related VP shunt revision were compared between patients who underwent VP shunt placement along the same track and those who underwent VP shunt placement at a different site (contralateral or posterior) from the initial EVD.

RESULTS

A total of 443 patients were admitted for the management of aSAH. Eighty of these patients eventually required VP shunt placement. Thirty-two patients (40%) had been treated with stent-assisted coiling or flow diverters and required DAPT, whereas 48 patients (60%) had been treated with coiling without stents or surgical clipping and were not on DAPT at the time of VP shunt placement. A total of 8 cases (10%) of new hemorrhage were observed along the intracranial proximal catheter of the VP shunt. Seven of these hemorrhages were observed in patients on DAPT, and 1 occurred in a patient not on DAPT. After multivariate analysis, only DAPT was significantly associated with hemorrhage (OR 31.23, 95% CI 2.98-327.32; p = 0.0001). One patient (3%) on DAPT who experienced hemorrhage required shunt revision for hemorrhage-associated proximal catheter blockage. The remaining 7 hemorrhages were clinically insignificant. The difference in rates of hemorrhage between shunt placement along the same track and placement at a different site of 0.07 was not significant (6/47 vs 2/32, p = 0.46). The difference in infection-related VP shunt revision rate was not significantly different (1/47 vs 3/32, p = 0.2978).

CONCLUSIONS

This clinical series confirms that, in patients with ruptured aneurysms who are candidates for stent-assisted coiling or flow diversion, the risk of clinically significant VP shunt-associated hemorrhage with DAPT is low. In an era of evolving endovascular therapeutics, stenting or flow diversion is a viable option in select aSAH patients.

Comparative study of perioperative complication rates of cervical laminoplasty performed by residents and teaching neurosurgeons

Early surgical education is required for neurosurgical residents to learn many surgical procedures. However, the participation of less experienced residents may increase perioperative complication rates. Perioperative complication studies in the field of neurosurgery are being increasingly published; however, studies have not yet focused on cervical laminoplasty. The study population included 193 consecutive patients who underwent cervical laminoplasty in Tokyo Metropolitan Neurological Hospital between 2008 and 2014. Patient and surgeon background factors, as well as perioperative complication rates were retrospectively compared between resident and board-certified spine neurosurgeon groups. Deteriorated or newly developed neurological deficits and surgical site complications within 30days of cervical laminoplasty were defined as perioperative complications. Out of 193 patients, 123 (64%) were operated on by residents as the first operator and 70 (36%) by board-certified spine neurosurgeons. No significant differences were observed in patient and surgeon factors between the two groups, except for hyperlipidemia (13 vs 17, p=0.02). Furthermore, no significant differences were noted in perioperative complication rates between the two groups (7 [5.7%] vs 4 [5.7%], p=1). Cervical laminoplasty performed in a standardized manner by residents who received their surgical training in our hospital did not increase perioperative complication rates, and ensured the safety of patients.

A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair

BACKGROUND

Frailty is a measure of physiologic reserve associated with increased vulnerability to adverse outcomes following surgery in older adults. The 'accumulating deficits' model of frailty has been applied to the NSQIP database, and an 11-item modified frailty index (mFI) has been validated. We developed a condensed 5-item frailty index and used this to assess the relationship between frailty and outcomes in patients undergoing paraesophageal hernia (PEH) repair.

METHODS

The NSQIP database was queried for ICD-9 and CPT codes associated with PEH repair. Subjects ≥60 years who underwent PEH repair between 2011 and 2013 were included. Five of the 11 mFI items present in the NSQIP data on the most consistent basis were selected for the condensed index. Univariate and multivariate logistic regressions were used to determine the validity of the 5-item mFI as a predictor of postoperative mortality, complications, readmission, and non-routine discharge.

RESULTS

A total of 3711 patients had data for all variables in the 5-item index, while 885 patients had complete data to calculate the 11-item mFI. After controlling for competing risk factors, including age, ASA score, wound classification, surgical approach, and procedure timing (emergent vs non-emergent), we found the 5-item mFI remained predictive of 30-day mortality and patients being discharged to a location other than home (p < 0.05). A weighted Kappa was calculated to assess agreement between the 5-item and 11-item mFI and was found to be 0.8709 (p < 0.001).

CONCLUSIONS

Frailty, as assessed by the 5-item mFI, is a reasonable alternative to the 11-item mFI in patients undergoing PEH repair. Utilization of the 5-item mFI allows for a significantly increased sample size compared to the 11-item mFI. Further study is necessary to determine whether the condensed 5-item mFI is a valid measure to assess frailty for other types of surgery.

Impact of resident involvement in outpatient otolaryngology procedures: An analysis of 17,647 cases

OBJECTIVE

This study examines the impact of resident physician participation on postoperative outcomes in outpatient otolaryngologic surgery.

STUDY DESIGN

Retrospective cohort.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for outpatient otolaryngologic procedures performed on adult patients. Cases were analyzed with the following cohorts: attending with resident or attending without resident. Outcomes included complications, readmission, reoperation, and operative time.

RESULTS

A total of 17,647 cases were analyzed, with 13,123 patients in the attending without resident cohort and 4,524 patients in the attending with resident cohort. The majority of patients were female (58.7%) and white (88.0%). The average age was 44 (range 16-89) years, and average body mass index was 29.0 ± 7.3 kg/m² . Total relative value units were higher in the attending with resident group 14.6 ± 12.0 compared with 10.2 ± 8.3 in the attending without resident group (P < 0.01). Univariate analysis revealed that resident participation increased complication rate (2.0% vs. 1.4%, P < 0.01) and operative time (108 ± 98 minutes vs. 60 ± 55 minutes, P < 0.01). There were no differences in readmissions (P = 0.35), reoperations (P > 0.05), or death rates (P = 0.32) between groups. Multivariate regression analysis, however, revealed that resident participation did not increase the rate of any complication, and that operative time was the only significantly impacted variable (P < 0.01).

CONCLUSION

Resident surgical training remains a vital component of the current health care system. Previous research has shown that, despite increased operative time, resident participation does not significantly impact complication rates for otolaryngology procedures. This study confirms these findings in the outpatient setting, thus reassuring both the surgeon and patients that resident participation does not impact procedural safety.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2026-2032, 2017.

Readmission and Other Adverse Events after Transsphenoidal Surgery: Prevalence, Timing, and Predictive Factors

BACKGROUND

Transsphenoidal surgery is a common neurosurgical procedure for accessing the pituitary and anterior skull base, yet few multicenter analyses have evaluated outcomes after this procedure.

STUDY DESIGN

Patients undergoing transsphenoidal surgery from 2006 to 2015 were extracted from the American College of Surgeons NSQIP database. Logistic regression was used to identify predictors of 30-day complications.

RESULTS

Of 1,240 patients included in this analysis, 6.9% experienced a major complication, and 9.4% experienced any complication within 30 days. Other adverse events included death in 0.7% and nonroutine hospital discharge in 5.3%. Most adverse events occurred within the first 2 weeks postoperatively; 82.9% of patients experienced their first complication during the initial hospital stay. Multivariable analysis demonstrated that predictors of hospital stay longer than 4 days included American Society of Anesthesiologists classification III to V (p = 0.015), insulin-dependent diabetes mellitus (p < 0.001), and operative time in the third and fourth quartiles (both p < 0.001). American Society of Anesthesiologists classification III to V and operative time in the fourth quartile were also predictors of any adverse event (p = 0.01 and p = 0.005, respectively). Among these patients, 3.7% underwent reoperation, the most common reason for which was postoperative cerebrospinal fluid leak (63.6%). Readmission occurred after 8.5% of cases at a median of 11.0 days post-discharge. The most common cause of readmission was hyponatremia (29.5%), followed by delayed postoperative cerebrospinal fluid leak (16.0%).

CONCLUSIONS

Overall rates of adverse events in patients undergoing transsphenoidal surgery are relatively low, and most occur before discharge from the hospital. Post-discharge complications associated with transsphenoidal surgery include deep vein thrombosis, pulmonary embolism, and urinary tract infection. Delayed postoperative cerebrospinal fluid leak is the major cause of reoperation, and hyponatremia is the major cause of readmission.

Does Trainee Involvement in Fluoroscopic Injections Affect Fluoroscopic Time, Immediate Pain Reduction, and Complication Rate?

BACKGROUND

Patients have expressed concern about undergoing procedures involving trainees, even with direct attending physician supervision. Little literature has examined the effect of trainee involvement on patient outcomes.

OBJECTIVE

We aimed to evaluate the effect of trainee involvement on patient complications, immediate pain reduction, and fluoroscopic time for different fluoroscopic injection types.

DESIGN

Retrospective review.

SETTING

Four academic outpatient institutions with Accreditation Council for Graduate Medical Education (ACGME)-accredited residency (physical medicine and rehabilitation, or anesthesiology) or fellowship (sports medicine or pain medicine) programs from 2000 to 2015.

PATIENTS

All patients receiving fluoroscopically guided hip (HI), sacroiliac joint (SIJI), transforaminal epidural (TFEI), and/or interlaminar epidural injections (ILEI, performed at only 1 institution).

METHODS

Outcome measures were examined based on the presence or absence of a trainee during the procedure.

MAIN OUTCOME MEASUREMENTS

The primary outcome was the number of immediate complications, with secondary outcomes being fluoroscopic time per injection (FTPI) and immediate numeric rating scale percentage improvement.

RESULTS

Trainees were involved in 67.0% of all injections (N = 7,833). Complication rates or improvements in numeric rating scale scores showed no significant differences with trainee involvement for any injection type (P > .05). Trainee involvement was associated with increased FTPI for ILEIs (18.2 ± 10.1 seconds with trainees versus 15.1 ± 8.5 seconds without trainees, P < .001), but not for HIs (P = .60) or SIJIs (P = .51). Trainee involvement with TFEIs was dependent on institution for outcome with respect to FTPI (P < .001), with 28.1 ± 17.9 seconds with trainees and 32.1 ± 22.1 seconds without trainees (P = 0.51).

CONCLUSIONS

This large multicenter study of academic institutions demonstrates that trainee involvement in fluoroscopically guided injections does not affect immediate patient complications or pain improvement. Trainee involvement does not increase fluoroscopic time for most injections, although there is an institutional difference seen. This study supports the notion that appropriate trainee supervision likely does not compromise patient safety for fluoroscopically guided injections.

LEVEL OF EVIDENCE

II.

Risk factors for post-operative respiratory failure among 94,621 neurosurgical patients from 2006 to 2013: a NSQIP analysis

INTRODUCTION

Post-operative respiratory failure can occur after neurosurgical operations. Identification of risk factors for respiratory failure after neurosurgery may help guide clinical decision-making, decrease length of stay, improve patient outcomes, and lower costs.

METHODS

We performed a search of the ACS-NSQIP database for all patients undergoing operations with a neurosurgeon from 2006 to 2013. We analyzed demographics, past medical history, and post-operative respiratory failure, defined as unplanned intubation and/or ventilator dependence for more than 48 h post-operatively.

RESULTS

Of 94,621 NSQIP-reported neurosurgical patients from 2006 to 2013, 2325 (2.5 %) developed post-operative respiratory failure. Of these patients, 1270 (54.6 %) were male, with an overall mean age of 60.59 years; 571 (24.56 %) were current smokers and 756 (32.52 %) were ventilator-dependent. Past medical history included dyspnea in 204 patients (8.8 %), COPD in 198 (8.5 %), and congestive heart failure in 66 (2.8 %). The rate of post-operative respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 (p < 0.001). Of the 2325 patients with respiratory failure, 1061 (45.6 %) underwent unplanned intubation post-operatively and 1900 (81.7 %) were ventilator-dependent for more than 48 h. The rate of both unplanned intubation (p < 0.001) and ventilator dependence (p < 0.001) decreased significantly from 2006 to 2013. Multivariate analysis demonstrated that significant risk factors for respiratory failure included inpatient status (p < 0.001, OR = 0.165), age (p < 0.001, OR = 1.014), diabetes (p = 0.001, OR = 1.489), functional dependence prior to surgery (p < 0.001, OR = 2.081), ventilator dependence (p < 0.001, OR = 10.304), hypertension requiring medication (p = 0.005, OR = 1.287), impaired sensorium (p < 0.001, OR = 2.054), CVA/stroke with or without neurological deficit (p < 0.001, OR = 2.662; p = 0.002, OR = 1.816), systemic sepsis (p < 0.001, OR = 1.916), prior operation within 30 days (p = 0.026, OR = 1.439), and operation type (cranial relative to spine, p < 0.001, OR = 4.344, Table 4).

CONCLUSIONS

Based on the NSQIP database, risk factors for respiratory failure after neurosurgery include pre-operative ventilator dependence, alcohol use, functional dependence prior to surgery, stroke, and recent operation. The overall rate of respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 according to these data.

Impact of Resident Participation on Outcomes After Single-Level Anterior Cervical Diskectomy and Fusion: An Analysis of 3265 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

STUDY DESIGN

Multicenter retrospective cohort study.

OBJECTIVE

To investigate the relationship between resident involvement in the operating room and 30-day complication rates in patients undergoing single-level anterior cervical diskectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

Although an integral part of academic medicine, surgical resident participation in the operating room and its impact on patient outcomes have been a topic of debate. No large-scale study has been performed to examine this relationship in ACDF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was retrospectively reviewed to identify all patients who underwent single-level ACDF procedures during 2006-2013. A propensity score-matching algorithm was employed to minimize baseline differences. Multivariate logistic regression analysis of unadjusted and propensity-matched cohorts was performed to examine the effect of resident participation on 30-day postoperative complication rates and length of hospital stay.

RESULTS

A total of 3265 patients met inclusion criteria. The propensity score-matching procedure yielded 1003 pairs of well-matched nonresident and resident pairs. The multivariate analysis of propensity score-matched population demonstrated that resident involvement was not associated with an increased risk for any of the complications analyzed, including overall complications, medical complications, surgical complications, mortality, cardiac arrest, deep venous thrombosis, or length of total hospital stay.

CONCLUSION

This large-scale, population-based study found that surgical resident participation in the operating room did not increase the risk of 30-day complications nor prolonged the length of hospital stay. Resident participation, however, was associated with an increased operative duration. Strategies to improve residents' technical proficiency outside of the operating room may enhance patient safety.

LEVEL OF EVIDENCE

3.

Neurosurgical resident education in Europe--results of a multinational survey

INTRODUCTION

Neurosurgical training aims at educating future generations of specialist neurosurgeons and at providing the highest-quality medical services to patients. Attaining and maintaining these highest standards constitutes a major responsibility of academic or other training medical centers.

METHODS

An electronic survey was sent to European neurosurgical residents between 06/2014 and 03/2015. Multiple logistic regression analysis was used to assess the effect size of the relationship between responder-specific variables (e.g., age, gender, postgraduate year (PGY), country) and the outcomes (e.g., satisfaction).

RESULTS

A total of 652 responses were collected, of which n = 532 were taken into consideration. Eighty-five percent were 26-35 years old, 76 % male, 62 % PGY 4 or higher, and 73.5 % working at a university clinic. Satisfaction rates with theoretical education such as clinical lectures (overall: 50.2 %), anatomical lectures (31.2 %), amongst others, differed largely between the EANS member countries. Likewise, satisfaction rates with practical aspects of training such as hands-on surgical experience (overall: 73.9 %), microsurgical training (52.5 %), simulator training (13.4 %), amongst others, were highly country-dependant. In general, 89.1 % of European residents carried out the first surgical procedure under supervision within the first year of training. Supervised lumbar-/cervical spine surgeries were performed by 78.2 and 17.9 % of European residents within 12 and 24 months of training, respectively, and 54.6 % of European residents operate a cranial case within the first 36 months of training. Logistic regression analysis identified countries where residents were much more or much less likely to operate as primary surgeons compared to the European average. The caseload of craniotomies per trainee (overall: 30.6 % ≥10 craniotomies/month) and spinal procedures (overall: 29.7 % ≥10 spinal surgeries/month) varied throughout the countries and was significantly associated with more advanced residency (craniotomy: OR 1.35, 95 % CI 1.18-1.53, p < 0.001; spinal surgery: OR 1.37, 95 % CI 1.20-1.57, p < 0.001).

CONCLUSIONS

Theoretical and practical aspects of neurosurgical training are highly variable throughout European countries, despite some efforts within the last two decades to harmonize this. Some countries are rated significantly above (and others significantly below) the current European average for several analyzed parameters. It is hoped that the results of this survey should provide the incentive as well as the opportunity for a critical analysis of the local conditions for all training centers, but especially those in countries scoring significantly below the European average.