Patel, Naresh P

Abstract BACKGROUND Trends in Medicare billing and procedural reimbursement for outpatient office visits remain unclear within the field of neurosurgery. OBJECTIVE To analyze financial trends of neurosurgeon reimbursement for Medicare office visits in 2010 compared to 2018. METHODS The 2010 and 2018 physician/supplier files from the Centers for Medicare and Medicaid Services website were utilized. All payments submitted by neurosurgeons (provider ID 14) were included. Trends in office visit Current Procedural Terminology codes 99201 to 99205 and 99211 to 99215 were analyzed. RESULTS Neurosurgeons billed for 1 109 979 office visits (463 611 h) in 2010 and Medicare denied 63 704 payments (totaling $11 205 283). Neurosurgeons billed for 1 189 046 office visits (508 526 h) in 2018 and Medicare denied 57 048 payments (totaling $15 103 879). This is a 7.1% increase in total neurosurgery office visits billed to Medicare, 9.7% increase in total office hours, and 34.8% increase in the payment amounts denied over 8 yr. Furthermore, after adjusting for inflation, the average amount paid to physicians by Medicare decreased by 8.3% per office visit. Additionally, Medicare paid 36.1% of the total neurosurgeon submitted charge amount for all office visits in 2010 but paid only 27.8% in 2018 (−8.3%). CONCLUSION Neurosurgeons are performing more office visits and billing for more time with patients. Meanwhile, Medicare has been paying physicians less per office visit, denying higher amounts of payments and reimbursing a decreasing percentage of submitted charges for office visits. An understanding of these trends is necessary to ensure continued equity and quality access to neurosurgical care in the United States.

Objective:Radiation therapy (RT) is the primary treatment of intracranial metastasis (ICM) from lung cancer (LC). Radiation necrosis (RN) has been reported post-RT with an incidence of 5% to 24%. We reviewed the spectrum of imaging changes in patients treated with RT for ICM from LC in an effort to identify potential risk factors for RN.Methods:We reviewed 63 patients with LC and ICM who received RT (radiosurgery [stereotactic radiosurgery] with/without whole brain radiation therapy) at our institution between 2013 and 2018. Data evaluated included demographics, tumor type, ICM burden and location, chemotherapy, surgery, and RT details as well as treatment choices and outcomes.Results:Of the 63 patients, clinical and radiographic criteria for RN were noted in 24 (38%) as early as 2 months and as late as 5 years posttreatment. Six patients required surgical resection due to refractory symptoms revealing pathology-proven RN and occasionally tumor. Patients were significantly more likely to develop RN if they had surgical resection of an ICM (45.8% vs. 20.5%,P=0.05). No differences were found in location, size, or genetic profile of lesions. In total, 80% of patients received treatment for symptoms and/or radiographic change. This was generally a combination of steroids, bevacizumab, laser interstitial thermal treatment, or surgical resection. Most patients required >1 treatment modality.Conclusions:This review of outcomes of RT for ICM in LC demonstrates a higher rate of RN than previously reported in the literature in those having had a surgical resection plus stereotactic radiosurgery. Our observation of RN as late as 5 years post-RT for ICM necessitates clinician awareness.

Abstract BACKGROUND AND IMPORTANCE Deep brain stimulation (DBS) is a well-established treatment for medically refractory Parkinson's disease (PD), essential tremor (ET), and dystonia. The field of DBS is expanding and techniques are under investigation for the treatment of several neurological disorders. A critical component of the success of these procedures depends significantly on the reliability and durability of devices implanted. Immediate feedback during surgery often gives the surgeon and patient a sense of confidence of long term success. When impedances are found to be elevated during the implantation of the DBS leads, appropriate trouble shooting measures are critical. CLINICAL PRESENTATION We present a 73-yr-old male undergoing awake subthalamic DBS with microelectrode recordings for severe PD. Once the optimal trajectory and depth were ascertained, the permanent DBS electrode was placed. High impedances were recorded. Troubleshooting procedures were performed and were all negative as to the cause of the values. Correct impedance levels of the DBS electrode was confirmed with extracranial testing, but continued high values were found again with intracranial positioning of the electrode. A postoperative computerized tomography (CT) scan confirmed intracranial air surrounding all of the contacts. The patient went on to outpatient programming with excellent clinical results. CONCLUSION The presence of pneumocephalus surrounding the DBS lead contacts at the target nucleus may have accounted for the intraoperative impedance findings. When all troubleshooting checks have not identified an explanation for the high impedances, intraoperative imaging may demonstrate pneumocephalus around the lead contacts, which should resolve and impedances return to normal values.

OBJECTIVEThere is currently a paucity of literature evaluating procedural reimbursements and financial trends in neurosurgery. A comprehensive understanding of the economic trends and financial health of neurosurgery is important to ensure the sustained success and growth of the specialty moving forward. The purpose of this study was to evaluate monetary trends of the 10 most common spinal and cranial neurosurgical procedures in Medicare reimbursement rates from 2000 to 2018.METHODSThe Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services was queried for each of the top 10 most utilized Current Procedural Terminology codes in both spinal and cranial neurosurgery, and comprehensive reimbursement data were extracted. The raw percent change in Medicare reimbursement rate from 2000 to 2018 was calculated for each procedure and averaged. This was then compared to the percent change in consumer price index over the same time. Using data adjusted for inflation, trend analysis was performed for all included procedures. Adjusted R-squared and both the average annual and the total percent change in reimbursement were calculated based on these adjusted trends for all included procedures. Likewise, the compound annual growth rate was calculated for all procedures.RESULTSWhen all reimbursement data were adjusted for inflation, the average reimbursement for all procedures decreased by an average of 25.80% from 2000 to 2018. From 2000 to 2018, the adjusted reimbursement rate for all included procedures decreased by an average of 1.59% each year and experienced an average compound annual growth rate of −1.66%, indicating a steady annual decline in reimbursement when adjusted for inflation.CONCLUSIONSThis is the first study to evaluate comprehensive trends in Medicare reimbursement in neurosurgery. When adjusted for inflation, Medicare reimbursement for all included procedures has steadily decreased from 2000 to 2018, with similar rates of decline observed between cranial and spinal neurosurgery procedures. Increased awareness and consideration of these trends will be important moving forward for policy makers, hospitals, and neurosurgeons as continued progress is made to advance agreeable reimbursement models that allow for the sustained growth of neurosurgery in the United States.

Pial arteriovenous fistulae (AVFs) are rare vascular abnormalities that are distinct from arteriovenous malformations and dural AVFs. These vascular lesions have been linked with trauma, ischemic syndromes, venous thrombotic diseases, and intracranial surgical procedures. In this report we describe a case of an intracranial ruptured pial AVF immediately following uneventful spinal surgery in an elderly patient with subsequent spontaneous resolution. He was a previous heavy smoker with a 60-pack-year history and alcohol abuse. His examination was positive for morbid obesity and mild weakness of the anterior tibialis and gastrocnemius muscles bilaterally. He underwent uneventful spinal surgery, suffering a generalized seizure shortly after extubation. Imaging studies demonstrated acute subarachnoid hemorrhage and cerebral angiography identified a pial AVF. He was stabilized medically and follow-up angiography demonstrated spontaneous resolution of the pial AVF. This case highlights a rare vascular malformation with rupture following uneventful spinal surgery.

ObjectiveIgG4‐related disease (IgG4RD) causing sinonasal and skull base pathology is uncommonly described. We present a series of suspected IgG4RD patients, with a pertinent review of the literature to highlight diagnostic challenges.Study DesignCase series.SettingAcademic tertiary care center.Subjects and MethodsCase series of patients with IgG4RD or suspected IgG4RD involving the sinonasal cavity and skull base.ResultsWe present 4 patients with atypical sinonasal and/or skull base disease who were noted to have IgG4‐positive plasma cell infiltration on immunohistochemistry of biopsy specimens. IgG4RD, a recently described entity affecting multiple organs, is characterized by lymphoplasmacytic infiltration and often elevated serum IgG4. IgG4RD can masquerade as malignancy or infection but responds to glucocorticosteroid and immunosuppressant therapy. IgG4RD has been infrequently reported presenting as sinonasal or skull base lesions, and definitive diagnostic criteria for these regions are not established. In our series, IgG4RD was suspected in all 4 patients, but only 1 met all current criteria for definitive diagnosis. All 4 patients, however, responded to corticosteroid therapy, and 1 was placed on long‐term azathioprine.ConclusionIgG4RD is rarely described in the sinonasal cavity and skull base, and specific diagnostic criteria for such disease have not been defined. We present a series of patients with IgG4‐positive plasma cell inflammatory pathology who were suspected to have IgG4RD. Our series highlights diagnostic challenges associated with these patients. Tumefactive and destructive sinonasal‐skull base lesions with a plasma cell‐rich infiltrate should incite suspicion of IgG4RD, and immunohistochemistry for IgG4‐positive plasma cells should be performed.

Objectives/HypothesisTo study reports of abducens nerve palsy following dural puncture procedures and to discuss possible etiologic theories, treatment, and prognosis.Study DesignSystematic review of peer‐reviewed literature.MethodsA systematic literature review was conducted (PubMed, 1950 to September 2011) for cases of sixth cranial nerve palsy following dural puncture procedures.ResultsWe report a case of abducens nerve palsy following lumbar drain placement for endoscopic trans‐sphenoidal pituitary macroadenoma resection. Sixth nerve palsy was noted immediately after surgery. Postoperative computed tomography and magnetic resonance imaging revealed no injury to the nerve or surrounding structures. A systematic literature review conducted for cases of abducens nerve palsy following dural puncture procedures found 22 studies (17 case reports and five case series). Twenty‐eight patients with temporary or permanent abducens nerve palsy were reported. Procedures included diagnostic lumbar puncture, spinal anesthesia, intrathecal catheterization, and shunting. Traction and local ischemia due to intracranial hypotension at the petroclival junction were proposed as causes of palsy.ConclusionsLumbar puncture procedures carry a rare risk of abducens nerve palsy from ischemic or traction injury. Routine use of lumbar drain during endoscopic skull base surgery is not without risk, and need for its placement should be carefully determined. Knowledge of such rare complications is helpful in risk–benefit analysis as endoscopic skull base techniques gain popularity.Level of Evidence4. Laryngoscope, 123:2633–2638, 2013

When coupled with classical clinical signs and symptoms, magnetic resonance imaging can significantly aid in the diagnosis of multiple sclerosis (MS). However, the differential diagnosis of multiple sclerosis is large and, in the absence of pathognomonic clinical features, can be challenging to diagnose initially. Some conditions, such as primary central nervous system lymphoma (PCNSL) and progressive multifocal leukoencephalopathy (PML), can mimic clinically some of the symptoms prominent in multiple sclerosis. Early treatment with corticosteroids can dramatically improve patient symptoms in MS and PCNSL. We report a case of a man diagnosed with histologically confirmed relapsing remitting multiple sclerosis who subsequently developed histologically confirmed primary central nervous system lymphoma. Immunosuppressant therapy in the treatment of multiple sclerosis may be a potential catalyst in the development of central nervous system lymphoma. The course of his disease and treatment are presented and the current literature reviewed.

Iatrogenic spinal arachnoid cysts are rare, but have been described as a complication of spinal injection and lumbar puncture procedures. The authors describe 2 cases of iatrogenic spinal arachnoid cyst formation that occurred after incidental durotomy during lumbar spine surgery. In both cases, postoperative MR imaging revealed compression of the cauda equina by an intradural arachnoid cyst. Intradural exploration and fenestration of the arachnoid cyst was accomplished in each case. This entity should be considered in the differential diagnosis of a patient experiencing symptoms of neurological compression after a lumbar surgery complicated by incidental durotomy.