Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative condition with a rapid disease course and a mortality rate of 100%. Several forms of the disease have been described, and the most common is the sporadic type. The most challenging aspect of this disease is its diagnosis—the gold standard for definitive diagnosis is considered to be histopatho-logical confirmation—but newer tests are providing means for an antemortem diagnosis in ways less invasive than brain biopsy. Imaging studies, electroencephalography, and biomarkers are used in conjunction with the clinical picture to try to make the diagnosis of CJD without brain tissue samples, and all of these are reviewed in this article. The current diagnostic criteria are limited; test sensitivity and specificity varies with the genetics of the disease as well as the clinical stage. Physicians may be unsure of all diagnostic testing available, and may order outdated tests or prematurely request a brain biopsy when the diagnostic workup is incomplete. The authors review CJD, discuss the role of brain biopsy in this patient population, provide a diagnostic pathway for the patient presenting with rapidly progressive dementia, and propose newer diagnostic criteria.

ObjectiveWe investigate the cost-effectiveness of adding robotic technology in spine surgery to an active neurosurgical practice. MethodsThe time of operative procedures, infection rates, revision rates, length of stay, and possible conversion of open to minimally invasive spine surgery (MIS) secondary to robotic image guidance technology were calculated using a combination of institution-specific and national data points. This cost matrix was subsequently applied to 1 year of elective clinical case volume at an academic practice with regard to payor mix, procedural mix, and procedural revenue. ResultsA total of 1,985 elective cases were analyzed over a 1-year period; of these, 557 thoracolumbar cases (28%) were analyzed. Fifty-eight (10.4%) were MIS fusions. Independent review determined an additional ~10% cases (50) to be candidates for MIS fusion. Furthermore, 41.4% patients had governmental insurance, while 58.6% had commercial insurance. The weighted average diagnosis-related group reimbursement for thoracolumbar procedures for the hospital system was calculated to be $25,057 for Medicare and $42,096 for commercial insurance. Time savings averaged 3.4 minutes per 1-level MIS procedure with robotic technology, resulting in annual savings of $5,713. Improved pedicle screw accuracy secondary to robotic technology would have resulted in 9.47 revisions being avoided, with cost savings of $314,661. Under appropriate payor mix components, robotic technology would have converted 31 Medicare and 18 commercial patients from open to MIS. This would have resulted in 140 fewer total hospital admission days ($251,860) and avoided 2.3 infections ($36,312). Robotic surgery resulted in immediate conservative savings estimate of $608,546 during a 1-year period at an academic center performing 557 elective thoracolumbar instrumentation cases. ConclusionApplication of robotic spine surgery is cost-effective, resulting in lesser revision surgery, lower infection rates, reduced length of stay, and shorter operative time. Further research is warranted, evaluating the financial impact of robotic spine surgery.

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Object Complications following lumboperitoneal (LP) shunting have been reported in 18% to 85% of cases. The need for multiple revision surgeries, development of iatrogenic Chiari malformation, and frequent wound complications have prompted many to abandon this procedure altogether for the treatment of idiopathic benign intracranial hypertension (pseudotumor cerebri), in favor of ventriculoperitoneal (VP) shunting. A direct comparison of the complication rates and health care charges between first-choice LP versus VP shunting is presented. Methods The Nationwide Inpatient Sample database was queried for all patients with the diagnosis of benign intracranial hypertension (International Classification of Diseases, Ninth Revision, code 348.2) from 2005 to 2009. These data were stratified by operative intervention, with demographic and hospitalization charge data generated for each. Results A weighted sample of 4480 patients was identified as having the diagnosis of idiopathic intracranial hypertension (IIH), with 2505 undergoing first-time VP shunt placement and 1754 undergoing initial LP shunt placement. Revision surgery occurred in 3.9% of admissions (n = 98) for VP shunts and in 7.0% of admissions (n = 123) for LP shunts (p < 0.0001). Ventriculoperitoneal shunts were placed at teaching institutions in 83.8% of cases, compared with only 77.3% of first-time LP shunts (p < 0.0001). Mean hospital length of stay (LOS) significantly differed between primary VP (3 days) and primary LP shunt procedures (4 days, p < 0.0001). The summed charges for the revisions of 92 VP shunts ($3,453,956) and those of the 6 VP shunt removals ($272,484) totaled $3,726,352 over 5 years for the study population. The summed charges for revision of 70 LP shunts ($2,229,430) and those of the 53 LP shunt removals ($3,125,569) totaled $5,408,679 over 5 years for the study population. Conclusions The presented results appear to call into question the selection of LP shunt placement as primary treatment for IIH, as this procedure is associated with a significantly greater likelihood of need for shunt revision, increased LOS, and greater overall charges to the health care system.

OBJECTIVEAdolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. Limited literature exists defining risk factors associated with outcomes during initial hospitalization in these patients. In this study, the authors investigated patient demographics, clinical and hospital characteristics impacting short-term outcomes, and costs in adolescent patients undergoing surgical deformity correction for idiopathic scoliosis. Additionally, the authors elucidate the impact of hospital surgical volume on outcomes for these patients.METHODSUsing the National Inpatient Sample database and appropriate International Classification of Diseases, 9th Revision codes, the authors identified adolescent patients (10–19 years of age) undergoing surgical deformity correction for idiopathic scoliosis during 2001–2014. For national estimates, appropriate weights provided by the Agency of Healthcare Research and Quality were used. Multivariable regression techniques were employed to assess the association of risk factors with discharge disposition, postsurgical neurological complications, length of hospital stay, and hospitalization costs.RESULTSOverall, 75,106 adolescent patients underwent surgical deformity correction. The rates of postsurgical complications were estimated at 0.9% for neurological issues, 2.8% for respiratory complications, 0.8% for cardiac complications, 0.4% for infections, 2.7% for gastrointestinal complications, 0.1% for venous thromboembolic events, and 0.1% for acute renal failure. Overall, patients stayed at the hospital for an average of 5.72 days (median 5 days) and on average incurred hospitalization costs estimated at $54,997 (median $47,909). As compared with patients at low-volume centers (≤ 50 operations/year), those undergoing surgical deformity correction at high-volume centers (> 50/year) had a significantly lower likelihood of an unfavorable discharge (discharge to rehabilitation) (OR 1.16, 95% CI 1.03–1.30, p = 0.016) and incurred lower costs (mean $33,462 vs $56,436, p < 0.001) but had a longer duration of stay (mean 6 vs 5.65 days, p = 0.002). In terms of neurological complications, no significant differences in the odds ratios were noted between high- and low-volume centers (OR 1.23, 95% CI 0.97–1.55, p = 0.091).CONCLUSIONSThis study provides insight into the clinical characteristics of AIS patients and their postoperative outcomes following deformity correction as they relate to hospital volume. It provides information regarding independent risk factors for unfavorable discharge and neurological complications following surgery for AIS. The proposed estimates could be used as an adjunct to clinical judgment in presurgical planning, risk stratification, and cost containment.