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We evaluated the effects of using a navigation technique with anterior approach surgery for thoracolumbar burst fractures on vertebral body screw placement and discussed its effects on the long-term prognosis of patients.We performed a prospective study of patients who had undergone anterior approach thoracolumbar surgery from May 2018 to August 2019. The 40 patients were randomly divided into the navigation group (NG) and control group (CG). In the NG, vertebral body screw placement was performed with 2-dimensional navigation guidance. For the CG, no navigation guidance was used. The clinical and radiological evaluations of the 2 groups were compared preoperatively, immediately after surgery, and at the final follow-up. Paired t tests and the χNo differences were found in the hospital stay, operation time, autologous blood recovery, postoperative drainage volume, Cobb angle of the preoperative coronal plane and sagittal plane, postoperative sagittal plane, postoperative Cobb angle of the coronal and sagittal planes measured on radiographs and computed tomography scans between the 2 groups (P0.05). The correction of the kyphosis deformity of the fracture segment was better in both groups (P0.001). The intraoperative blood loss and Cobb angle of the postoperative coronal plane in the NG was less than that in the CG (P0.05). Also, the 4 vertebral body screws in the NG were more parallel to the endplate than were those in the CG.We found that the use of navigation can improve the accuracy of screw placement in anterior approach surgery for thoracolumbar burst fractures and improve patients' long-term prognosis.

Objective Subgaleal drains are generally deemed necessary for cranial surgeries including decompressive craniectomies (DCs) to avoid excessive postoperative subgaleal hematoma (SGH) formation. Many surgeries have moved away from routine prophylactic drainage but the role of subgaleal drainage in cranial surgeries has not been addressed. Methods This was a randomized controlled trial at 2 centers. A total of 78 patients requiring DC were randomized in a 1:1:1 ratio into 3 groups: vacuum drains (VD), passive drains (PD), and no drains (ND). Complications studied were need for surgical revision, SGH amount, new remote hematomas, postcraniectomy hydrocephalus (PCH), functional outcomes, and mortality. Results Only 1 VD patient required surgical revision to evacuate SGH. There was no difference in SGH thickness and volume among the 3 drain types (P = 0.171 and P = 0.320, respectively). Rate of new remote hematoma and PCH was not significantly different (P = 0.647 and P = 0.083, respectively), but the ND group did not have any patient with PCH. In the subgroup analysis of 49 patients with traumatic brain injury, the SGH amount of the PD and ND group was significantly higher than that of the VD group. However, these higher amounts did not translate as a significant risk factor for poor functional outcome or mortality. VD may have better functional outcome and mortality. Conclusions In terms of complication rates, VD, PD, and ND may be used safely in DC. A higher amount of SGH was not associated with poorer outcomes. Further studies are needed to clarify the advantage of VD regarding functional outcome and mortality, and if ND reduces PCH rates.

Postoperative pain in spine surgery is an issue. Erector spinae plane block (ESPB) may reduce such postoperative pain, but its usefulness has never been evaluated in the specific context of trauma surgery. We thus studied the effect of bilateral ultrasound-guided ESPB on postoperative pain and opioid requirement after percutaneous lumbar arthrodesis for trauma.All patients who underwent percutaneous lumbar arthrodesis for spine trauma between December 2019 and March 2020 were retrospectively studied. Some patients received preoperative bilateral ESPB (30 mL of 0.375% ropivacaine on each side; ESPB group), others received the standard of care (i.e., postoperative muscular infiltration with 30 mL of 0.75% of ropivacaine; control group), according to the preference of the anesthesiologist in charge of the patient. The rest of the management was identical in all patients. The primary outcome was the cumulative morphine consumption at 24 hours postoperatively. Secondary outcomes included pain score at various time points until 24 hours.Fifty-five patients were included, of whom 24 received an EPSB and 31 received the standard of care. The cumulative morphine consumption (mean [standard deviation]) at 24 hours was 13 (12) mg in the ESPB group, and 35 (17) mg in the control group (P0.001). Pain scores were significantly lower in the ESPB group compared with the control group up to 9 hours after surgery (P0.01).In this pilot study, compared with standard analgesia, ESPB reduced opioid requirement and postoperative pain after percutaneous lumbar arthrodesis for trauma. A randomized controlled trial is required to prove this effectiveness.

Robotic guidance (RG) pedicle screw placement has been increasingly used to improve the rate of insertion accuracy. However, the superiority of the RG technique over computer-assisted navigation (CAN) remains debatable.To determine whether the Mazor RG technique is superior to CAN in terms of the rate of insertion accuracy and 4 other clinical indices, namely, intraoperative time, blood loss, complications and revision surgery caused by malposition.A search of PubMed, Embase, Cochrane, Web of Science, CNKI, and WanFang was conducted. We mainly aimed to evaluate the accuracy of pedicle screw placement between the Mazor RG and CAN techniques. The secondary objectives were intraoperative time, blood loss, complications, and revision surgery caused by malposition. The meta-analysis was conducted using the RevMan 5.3 and Stata 15.1 software.A randomized controlled trial and 5 comparative cohort studies consisting of 529 patients and 4081 pedicle screws were included in this meta-analysis. The RG technique has a significantly higher accuracy than CAN in terms of optimal (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.85-2.76; P0.01) and clinically acceptable (OR, 1.69; 95% CI, 1.22-2.34; P = 0.002) pedicle screw insertions. Furthermore, the RG technique showed significantly less blood loss (mean difference, -42.49; 95% CI, -78.38 to -6.61; P = 0.02) than did the CAN technique but has equivalent intraoperative time (mean difference, 0.75; 95% CI, -5.89 to 7.40; P = 0.82), complications (OR, 0.65; 95% CI, 0.32-1.33, P = 0.24), and revision surgery caused by malposition (OR, 0.46; 95% CI, 0.15-1.43, P = 0.18).The Mazor RG technique is superior to CAN concerning the accuracy of pedicle screw placement. Thus, the Mazor RG technique is accurate and safe in clinical application.

We sought to evaluate the efficacy and safety of lumbar fusion versus nonoperative care for the treatment of chronic low back pain associated with degenerative disk disease.A comprehensive duplicate electronic database search including PubMed, Embase, Cochrane Library, and China National Knowledge Infrastructure was conducted to identify relevant prospective studies published up to June 30, 2020. The main outcomes including clinical results, complications, and all-cause additional surgeries were presented in the form of short- (2 years) and long-term (≥2 years) follow-up results. Analyses were performed in Review Manager software 5.3.Six prospective studies involving 159 patients for short-term follow-up and 675 for long-term follow-up were included. The 2 interventions exhibited little difference in regard to short- and long-term Oswestry Disability Index and visual analog scale scores for back and leg pain, except that lumbar fusion might bring about lower additional surgery rate (risk ratio, 0.40; 95% confidence interval, 0.17 to 0.98; P = 0.04), and higher complication rate (risk ratio, 21.46; 95% confidence interval, 4.34 to 106.04; P = 0.0002) in the long term.The present meta-analysis determined that fusion surgery was no better than nonoperative treatment in terms of the pain and disability outcomes at either short- or long-term follow-up. It is necessary for clinicians to weigh the risk of complications associated with fusion surgery against additional surgeries after nonoperative treatment. Considering lax patient inclusion criteria in the existing randomized clinical trials, the result needs to be further confirmed by high-quality research with stricter selection criteria in the future.

Background Intraventricular hemorrhage (IVH) is a rare cause of intracranial bleeding across all age groups, with dismal sequelae in most of the affected population. The reported data on IVH are numerous, with multiple levels of evidence. We performed a citation-based analysis to identify the most-cited reports on IVH. Methods A thorough search of the Scopus database was conducted using “intraventricular hemorrhage” as the search keyword. The 100 most cited studies were stratified in descending order. The reports were reviewed in-depth and categorized accordingly. Bibliometric parameters of interest were obtained for analysis. Results The most-cited studies had been published between 1927 and 2017. Most (n = 60) had been published between 1980 and 2000. The most-cited studies had received a total of 16,512 citations, with an average of 174 citations per report. Studies on pathogenesis were the most prolific, with 23 articles included. A total of 13 randomized controlled trials were identified. The top contributing country was the United States, with 67 reports. The leading institution was the Washington University School of Medicine in St. Louis, Missouri, with 11 studies. Pediatrics was the most active journal, with 20 studies. Conclusion The present collection of highly cited studies can aid in the understanding of chronological trends and could serve as an efficient guide to delineate the reports involved in the evidence-based practice of the management of IVH.

Background Neuromuscular electrical stimulation (NMES) has emerged as a viable alternative for venous thromboembolism prophylaxis. Electrical stimulation of the peroneal nerve using NMES may potentially interfere with somatosensory-evoked potential (SSEP) acquisition. This feasibility study evaluates a NMES device and its effect on SSEP acquisition as an initial step in a randomized clinical trial to assess NMES for intraoperative venous thromboembolism prophylaxis. Methods Healthy volunteers underwent SSEP testing during NMES in an outpatient setting. Concurrently, SSEP recordings of the posterior tibial nerve with stimulation at each ankle were obtained in 3 conditions: sham, NMES in place but inactive; ipsi, NMES active on leg ipsilateral to SSEP acquisition; and contra, NMES active on the leg contralateral to SSEP acquisition. Nonparametric statistical methods, including repeated measures, were used for data analysis. Results Stimulation intensities on the left, right, and bilaterally did not differ (P ≥ 0.20). Strong positive correlations were noted between the ipsilateral geko stimulus pulse width and ipsilateral SSEP stimulation intensities (left: rs = 0.866, P = 0.001; right: rs = 0.877, P = 0.001). Women required significantly greater pulse width settings than men (P = 0.01). Finally, visual inspection of waveforms, as used during dynamic IONM, did not show any significant variations of P37 cortical waveforms during NMES. Conclusions As a preliminary step to testing NMES intraoperatively for venous thromboembolism prophylaxis, interference with SSEP acquisition was investigated in the outpatient laboratory setting. Within a small sample of healthy volunteers, no significant changes were seen in P37 cortical latencies to suggest interference between the NMES device and SSEP waveforms.

This meta-analysis of published randomized controlled trials (RCTs) aimed to investigate the efficacy and safety of endovascular therapy (ET) for patients with acute ischemic stroke.The summary relative risks (RRs) with corresponding 95% confidence intervals were calculated to measure the effectiveness of ET using a random-effects model.Thirteen RCTs including 3408 patients were identified among 2851 initial electronic citations. Overall, the summary RR indicated that ET significantly increased the incidence of a modified Rankin Scale score of 0-2 (RR, 1.50; P0.001), asymptomatic intracerebral hemorrhage (IH) (RR, 1.42; P = 0.001), subarachnoid hemorrhage (RR, 2.36; P = 0.001), and major complications due to non-intracerebral bleeding (RR, 1.47; P = 0.014). However, ET had no significant effects on the risk of 7-day death (P = 0.827); death after 30 days (P = 0.085); symptomatic IH (P = 0.288); type 1 (P = 0.413), type 2 (P = 0.300), and total parenchymal hematoma (P = 0.160); intraventricular hemorrhage (P = 0.244); early neurologic deterioration (P = 0.570); recurrent stroke (P = 0.830); and symptomatic edema (P = 0.485).The findings of this meta-analysis suggest the incidence of a modified Rankin Scale score of 0-2 in patients who received ET was significantly increased. Moreover, the harmful effects of ET might exist due to greater risk of asymptomatic IH, subarachnoid hemorrhage, and non-intracerebral bleeding, and these results should be verified by further large-scale long-term RCT.

Increasing costs put the value of spine surgery under scrutiny. In health economics, cost-effectiveness analyses (CEA) are used to compare the value of competing procedures. However, inconsistent methodology prevents standardization and implementation of recommendations. The goal of this study is to perform a systematic review of all U.S. CEAs in spine surgery reported to date, highlight their strengths and weaknesses, and define metrics essential for high-quality CEAs.We followed AMSTAR systematic review methods, identifying all U.S. spine surgery CEAs reported to March 2019 with a structured, reproducible search of PubMed, Embase, and the Tufts CEA Registry.We identified 40 CEA studies. Twelve (30%) used outcome data from a randomized controlled trial. To calculate costs, 22 (55%) used allowed charges but costing methods were often unclear or imprecise. Studies applying discounting had mean follow-up of 5.92 years compared with 3.00 years for studies without. Eleven of 15 (73%) cervical studies compared cervical disc arthroplasty with anterior cervical discectomy and fusion, finding cervical disc arthroplasty to be cost-effective ($100,000/quality-adjusted life year) for 1-level and 2-level procedures. Eleven of 25 lumbar studies (44%) compared operative with nonoperative interventions for intervertebral disc herniation, lumbar stenosis, and lumbar spondylolisthesis. Lumbar studies comparing surgical with nonoperative intervention found surgery at least cost-effective for intervertebral disc herniation and lumbar stenosis, but cost-effective only for lumbar spondylolisthesis at 4 years follow-up. Most studies (70%) lacked appropriate sensitivity analyses.Costing methodology remains obscure and inconsistent and incremental cost-effectiveness ratio results incomparable. The language of costing methodology must be standardized and sensitivity analyses of outcome and cost inputs mandatory for publication.

Background Therapeutic hypothermia (TH) offers cerebral protection following ischemic stroke and may improve outcomes in conjunction with decompressive hemicraniectomy (DHC). We aimed to assess the effectiveness of TH in patients with malignant ischemic stroke and DHC. Methods We performed a meta-analysis in patients with malignant ischemic stroke undergoing DHC comparing TH versus normothermia in studies published up to August 2019. Included studies had ≥10 adults with acute ischemic stroke. Primary outcome was functional independence, and secondary outcomes included complications. Effect size was pooled and described by relative risk (RR) ratios and 95% confidence intervals (CIs). Results Five studies (n = 269 patients; n = 130 TH, n = 139 controls) were included, 4 of which were prospective (n = 2 randomized controlled trials). Median achieved body temperature of TH was 33.6°C (range 33°C−35°C). Median modified Rankin Scale at the study completion was similar between TH and controls (RR 1.08, 95% CI 0.56–2.07, P = 0.8). Three studies reported individual patient modified Rankin Scale outcomes demonstrated a shift toward worse outcomes with TH (unadjusted common odds ratio 1.74; 95% CI 1.05–2.88, P = 0.01). Overall complications were similar between groups (RR 1.20, 95% CI 0.70–2.05, random effects P = 0.5). A suggestion of higher mortality was seen in TH (RR 1.50, 95% CI 0.97–2.32, P = 0.07). Conclusions Clinical and functional outcomes were not overall different between patients undergoing systemic TH and controls following DHC despite the shift toward worse outcomes with TH observed in some studies.

Background Many treatment options for osteoporotic vertebral fractures are available. However, limited and variable findings have been reported on the efficacy of the individual therapies. The objective of the present study was to systematically review the reported data for evidence of efficacy of spinal orthoses for osteoporotic vertebral fractures. Methods A systematic review of the PubMed database was performed. Two reviewers evaluated the studies found for eligibility. Randomized controlled trails (RCTs) and prospective nonrandomized, prospective single-arm, and retrospective comparative studies of the treatment of acute osteoporotic vertebral fractures with spinal orthoses were included. Results A total of 16 studies were included: 5 RCTs, 6 nonrandomized prospective comparative studies, 1 retrospective case-control study, and 4 prospective single-arm studies. Of the 16 studies, 4 (3 single-arm studies and 1 nonrandomized study) provided low-quality evidence that bracing, with or without bedrest, was safe. Also, 1 nonrandomized and 1 single-arm study provided low-quality evidence that bracing improved pain and disability. In addition, 4 studies demonstrated that the use of a rigid brace was equivalent to the use of a soft brace or no brace (2 high-quality RCTs, 2 nonrandomized studies, 1 low-quality RCT). Two nonrandomized and one case-control study demonstrated a benefit of kyphoplasty compared with bracing alone (all low quality). Two RCTs had provided low-quality evidence that bracing was superior to no brace and one nonrandomized study provided low-quality evidence that a dynamic brace was superior to rigid orthosis. Conclusions Limited evidence has suggested the safety of spinal orthoses for the treatment of osteoporotic compression fractures. At present, compelling evidence is not available to suggest that a rigid brace is superior to a soft brace or no brace. Kyphoplasty might be of benefit for select patients.

We performed this meta-analysis to compare the safety of unilateral with bilateral instrumented fusion in 2-level degenerative disorders of the lumbar spine.We conducted an independent and a duplicate electronic database search including PubMed, Embase, and Cochrane Library until January 2020 for randomized controlled trials (RCTs) comparing unilateral pedicle screw fixation with bilateral pedicle screw fixation for multilevel lumbar degenerative disorders. Fusion and complication rates were the primary outcomes analyzed. Analysis was performed in R platform using OpenMeta[Analyst] software.Five RCTs including 215 patients (Unilateral/Bilateral = 106/109) were included in the meta-analysis. There was no significant difference between the 2 groups regarding fusion rate, complication rate, blood loss, duration of hospital stay, functional outcome scores like Visual Analog Scale, Oswestry Disability Index, and Short-Form 36 health survey at the final follow-up. Unilateral pedicle screw fixation was associated with a significant reduction in operation time (P0.001). Compared with the open approach, the minimally invasive approach showed a significant difference in terms of factors like operative time, blood loss, hospital stay, Visual Analog Scale, and Oswestry Disability Index (P = 0.004).Our meta-analysis establishes the immediate safety and significant lesser operative period of unilateral pedicle screw fixation in lumbar fusion. However, due to lack of evidence on complications like cage subsidence and adjacent segment disease, unilateral pedicle screw fixation cannot be recommended as an alternative to bilateral pedicle screw fixation for 2-level degenerative spinal disease. Our analysis established the lacunae in literature for high-quality evidence on the subject; hence we recommend further large multicenter studies with longer follow-up to arrive at a conclusion.

Background Numerous randomized controlled trials (RCTs) relevant to the cerebrovascular field have been performed. The fragility index was recently developed to complement the P value and measure the robustness and reproducibility of clinical findings of RCTs. Objective In this study, we evaluate the fragility index for key surgical and endovascular cerebrovascular RCTs and propose a novel RCT classification system based on the fragility index. Methods Cerebrovascular RCTs reported between 2000 and 2018 were reviewed. Six key areas were specifically targeted in relation to stroke, carotid stenosis, cerebral aneurysms, and subarachnoid hemorrhage. The correlation between fragility index, number of patients lost to follow-up, and fragility quotient were evaluated to propose a classification system for the robustness of the studies. Results A total of 20 RCTs that reported significant differences between both study groups in terms of the primary outcome were included. The median fragility index for the trials was 5.5. An additional 30 randomly selected RCTs were added to propose a classification system with high reliability. The difference between the number of patients lost to follow-up and fragility index inversely correlated with the fragility quotient and was used to divide the robustness of the RCTs into 3 classes reflecting the reproducibility of the trial. Conclusions Neurosurgeons and neurointerventionalists should exercise caution with interpreting the results of cerebrovascular RCTs, especially when the sample size and events numbers are small and there is a high number of patients who were lost to follow-up, as quantitatively identified using the proposed classification system.

Background Platelet-rich plasma (PRP) has been frequently used to enhance bone regeneration. A meta-analysis was conducted to systematically assess the fusion rate and pain relief of applying PRP during spinal fusion surgery. Methods Studies investigating spinal fusion surgery combined with PRP were retrieved from Medline and the Web of Science in accordance with the inclusion and exclusion criteria. A quality evaluation was conducted using the Cochrane collaboration tool for randomized controlled trials and the Newcastle-Ottawa scale quality assessment for cohort trials. Statistical analysis was performed using RevMan, version 5.3. Results A total of 12 studies, including 3 randomized controlled trials and 9 cohort studies, with 661 patients, were included in the present meta-analysis. The mean age was 52.3 ± 8.0 years. Overall, the pooled results demonstrated that the differences in the fusion rates between the PRP and non-PRP treatment groups were not statistically significant. The risk ratio was 1.01 (95% confidence interval, 0.95–1.06; P = 0.83). Also, no significant difference in pain relief measured using the visual analog scale was found between the 2 groups. The mean difference was −0.08 (95% confidence interval, −0.26 to 0.11; P = 0.42). conclusions Adding PRP did not increase the fusion rates from spinal fusion surgery. In addition, no significant difference was found in pain relief between the PRP and non-PRP treatment groups.

Objective The chronic subdural hematoma (cSDH)-Drain trial compared recurrence rates and clinical outcome associated with the use of subperiosteal drain (SPD) and subdural drain (SDD) after burr-hole drainage for cSDH. This subgroup analysis aimed to determine whether one drain type is preferable for patients treated with platelet inhibitors (PI) or anticoagulants (AC). Methods This subanalysis included 133 patients treated with PI/AC of the 220 patients from the preceding cSDH-Drain trial. For these patients the association between the drain type used and recurrence rates, mortality, as well as clinical outcome at 6 weeks and 12 months follow-up were analyzed using a logistic regression analysis model. Additionally, recurrence rates, clinical outcome, and mortality were assessed for each PI or AC type separately. Results The insertion of SPD was associated with 7.35% recurrence rates compared to 13.85% with SDD in patients treated with PI or AC (OR 0.41, 95% CI 0.06–2.65, P = 0.36). Outcome measurements and mortality did not differ significantly between both groups at 6-week and 12-month follow-up. In addition, there was no statistically significant association between drain type and recurrence rate or mortality when comparing data for each PI or AC type. At 24 hours postoperatively, significantly more patients under phenprocoumon and natrium-dalteparin had a Glasgow Coma Scale score between 13 and 15 in the SDD group compared with the SPD group (P = 0.006), whereaas at 6-week follow-up significantly more patients in the SDD group treated with ASA had a good modified Rankin scale score (P = 0.01). At 12 months, no significant difference in outcome measurements was seen for all PI and AC types. Conclusions In patients treated with PI or AC, the insertion of SPD after burr-hole drainage of cSDH showed comparable recurrence, mortality, and long term outcome rates when compared with SDD.

Background Numerous randomized controlled trials have shown that endovascular mechanical thrombectomy (MT) is an effective treatment for large vessel ischemic stroke. This study examines variation in rates of MT across the United States by geographic region and urban-rural areas to identify utilization disparities. Methods Data from the Global Burden of Disease Collaborative Network were used to determine acute ischemic stroke (AIS) incidence by state for 2016. The 2016 National Inpatient Sample was accessed to identify patients who underwent MT and patients who were diagnosed with cerebral infarct due to thrombosis or embolism of anterior circulation arteries representing the AIS population of interest. National Inpatient Sample data were used to create national weighted estimates of the size of subject populations, age at admission, length of stay, and discharge status. Results In the United States, approximately 13,010 mechanical thrombectomies were performed in 2016, representing 3.1% of the AIS population. Proportions of patients undergoing MT were highest in large central metropolitan areas and lowest in rural settings when compared with the national estimate. East North Central and West South Central regions had significantly lower proportions of patients treated with MT. Discharge destinations, a proxy for clinical outcome, differed significantly by region and urban-rural designation. Conclusions The number of MTs performed in 2016 increased approximately 1.3 times from 2015. Considering that 10%–17% of patients with AIS may be MT-eligible, current rates of MT are low across all regions, but the most pronounced disparities and poorer clinical outcomes occur in rural areas, particularly in the Northeast/Southwest regions of the Midwest.

Background In patients postcardiac arrest, it has been reported that the small value of the difference between mixed venous oxygen saturation (Sv o 2) and jugular venous oxygen saturation (Sjv o 2) is associated with poor neurologic outcome. However, the importance of the difference between mixed venous oxygen saturation and jugular venous oxygen saturation (ΔS o 2 [v − jv]) remains unknown in severe traumatic brain injury (TBI). The aim of this study was to examine whether ΔS o 2 (v − jv) is associated with neurologic outcome and mortality in patients with severe TBI. Methods We conducted post hoc analyses of the Brain Hypothermia Study, a multicenter randomized controlled trial of mild therapeutic hypothermia for the treatment of severe TBI. The value of ΔS o 2(v − jv) on day 1 and day 3 was compared between survivors (n = 65) and nonsurvivors (n = 25) or between patients with favorable (n = 47) and unfavorable (n = 43) neurologic outcomes. Results The reduction in ΔS o 2 (v − jv) on day 3 was −2.0% (range, −6.9% to 6.5%) in the nonsurvivor group and 6.3% (range, −2.5% to 16.7%) in the survivor group. The difference was statistically significant (P = 0.03). The same tendencies were observed in the nonsurvivor group on day 1 and in the unfavorable neurologic outcome group on day 1 and day 3, but the difference was not significant. Conclusions The reduction in ΔS o 2(v − jv) on day 3 was associated with high mortality in patients with severe TBI.

Background: Moyamoya syndrome, a progressive, idiopathic stenosis of the internal carotid arteries, results in increased risk for both ischemic and hemorrhagic strokes. Revascularization procedures have been shown in small studies to be both safe and efficacious for these patients; however, randomized controlled trials are lacking. The goal of this systematic review is to organize the literature evaluating surgical intervention versus conservative medical management. Methods: A systematic review was performed including studies with 3 or more participants with moyamoya syndrome in the setting of sickle cell disease and a measured outcome after either medical or surgical intervention. Relevant studies were identified using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria and a set of predetermined key words. Results: Sixty-one articles were identified with 6 articles ultimately included in this review (N = 122). Of the patients, 73 (59.8%) were revascularized surgically (all indirect procedures), whereas 49 (40.2%) remained on chronic transfusion therapy. Of the patients that underwent indirect revascularization surgery, a total of 1 perioperative (1.4%) and 4 postoperative strokes (5.5%) were reported over 44 months (1 stroke per 53.3 patient-years). In comparison, an average of 46.5% of patients who were receiving chronic transfusions had major events (stroke or transient ischemic attack) while undergoing therapy (1 stroke per 13.65 patient-years, P = 0.00215). Conclusions: We present a large systematic review of the literature regarding outcomes of surgical and medical management for patients with moyamoya syndrome and sickle cell disease. The findings redemonstrate the efficacy and safety of surgical revascularization, and advocate for earlier discussion around surgical intervention. © 2019 Elsevier Inc.

Dual and single antiplatelet therapies are routinely used in carotid artery endarterectomy (CEA). However, the efficacy and safety of these therapies are controversial. The present study aimed to comprehensively compare the clinical outcomes between dual and single antiplatelet therapies in CEA.This study retrieved available academic studies evaluating the complications related to antiplatelet therapy between dual and single antiplatelet therapies in CEA from the databases of ScienceDirect, the Cochrane Library, EMBASE, and PubMed. References to previous reviews and related clinical trials were manually checked to retrieve potential literature that was not included in our electronic search results.A total of 10 articles (1 randomized controlled trial, 9 non-randomized controlled trials) were included in the study. The overall number of patients in the dual antiplatelet group was 14,280, and the number of patients in the single antiplatelet group was 125,850. The results revealed that the single antiplatelet group had a lower incidence of 30-day death (rate difference [RD] 0.002; 95% confidence interval [CI] 0.000-0.003; P = 0.014), neck hematoma (odds ratio [OR] 2.120; 95% CI 1.431-3.142; P0.001), myocardial infarction (RD 0.004; 95% CI 0.001-0.007; P = 0.003), and major bleeding (RD 0.005; 95% CI 0.002-0.008; P0.001). Meanwhile, the single antiplatelet group was associated with a shorter operation time (weighted mean difference 4.000; 95% CI= 2.564-5.436; P0.001). However, there was no significant difference in the rate of postoperative transient ischemic attack (P = 0.215), stroke (P = 0.130), or length of stay (P = 0.563).Based on current evidence, using single antiplatelet therapy in CEA may reduce operation time and the incidences of 30-day death, neck hematoma, major bleeding, and myocardial infarction without increasing the risks of transient ischemic attack, stroke, or a longer operation time.

Background Chronic subdural hematoma (cSDH) is an increasingly common condition due to the growing use of anticoagulation. Currently, there remains a lack of evidence to guide the optimal timing of anticoagulant reinitiation for stroke prevention in atrial fibrillation after cSDH evacuation. We aimed to better understand the perceived risks of hemorrhagic and embolic complications along with current practice patterns on restarting anticoagulation after surgical evacuation of cSDH. Methods We conducted a survey of Canadian neurosurgeons and stroke neurologists using a novel self-administered questionnaire using clinical cases that included questions on clinical experience, practice setting, practice patterns, and perceptions on stroke/bleeding risk with anticoagulation reinitiation after cSDH evacuation. The instrument was evaluated for clinical sensibility by 5 neurosurgeons, neurologists, and intensivists. Results The response rate after 4 mailings was 40% for neurosurgeons (55/136) and 21% for stroke neurologists (26/122). Almost all participants would restart anticoagulation for stroke prevention in atrial fibrillation after cSDH evacuation (91.8% in low-risk patients, 98.6% in high-risk patients). Time to reinitiation of anticoagulation varied considerably, particularly for high-risk patients where 36% of participants would restart anticoagulation within 1 week of surgery, 44% between 1 and 4 weeks after surgery, and 19% after 4 weeks postoperatively. The perceived risk of stroke and SDH reaccumulation varied considerably among participants and was dependent on timing of anticoagulation reinitiation. Conclusions There is considerable variation in current practice patterns and perceived risks of embolic and hemorrhagic complications with anticoagulation reinitiation after cSDH evacuation. These results demonstrate clinical equipoise that warrant further targeted investigation in large-scale randomized controlled trials.

Background Most patients with glioma experience recurrence and have a poor prognosis. Scientometric analysis is effective and widely used to summarize the most influential studies within a certain field. We present the first scientometric analysis of recurrent glioma. Methods We conducted a generalized search for articles on recurrent glioma in the Web of Science database and evaluated the top 100 most cited articles among 4651 articles. Results The number of citations from the top 100 cited articles on recurrent glioma ranged from 149 to 1471; most of these articles were published in oncology-specific journals (66) and were submitted by institutions in the United States (n = 67). The top-cited articles consisted of 98 articles and 2 literature reviews. Articles were classified into 4 major categories based on subject matter: 82 pertained to treatment, 6 pertained to genetic mechanisms, 7 pertained to diagnosis, and 5 pertained to prognosis. Treatment-related articles were subdivided into the following 7 categories: targeted therapy (n = 21), chemotherapy (n = 20), immunotherapy (n = 12), combination therapy (n = 12), radiotherapy (n = 9), surgical resection (n = 6), a new therapy (physiotherapy) (n = 1), and treatment summary (n = 1). Conclusions The results of the analysis indicated that the core problem is the treatment of recurrent glioma. Although the number of citations on targeted therapy and combination therapy has increased in recent years, the proportion of randomized controlled trials, basic medical research, literature reviews, and meta-analyses is relatively low; thus, there is an urgent need to conduct these types of studies on recurrent glioma.

Background Acute pain control after supratentorial craniotomy is considered among the most important indicators of postoperative recovery. The aim of this study was to determine the effects of intravenous acetaminophen on postcraniotomy pain. Methods We searched databases including Embase, Scopus, Medline, Cochrane Library, and Web of Science until April 2019. Cochran Q test and I2 statistic were used to assess the heterogeneity across included clinical trials. Standardized mean difference (SMD) and 95% confidence interval (CI) were used to estimate pooled effect sizes. Results Out of 479 reports, 5 randomized controlled trials met the inclusion criteria and were appropriate for our meta-analysis, which included a total of 2635 patients. The pooled results of included clinical trials indicated that paracetamol intake significantly decreased rescue dose (SMD, −0.67; 95% CI, −1.15 to −0.19; P Conclusions The results of this systematic review and meta-analysis indicate that preoperative intravenous administration of acetaminophen is associated with decreased postoperative pain, need for rescue analgesics, and dosages of analgesics after craniotomy surgery.

Objective To perform a meta-analysis exploring the correlation between cervical lordosis (CL) and sagittal spine alignment in patients with adolescent idiopathic scoliosis (AIS) after surgery for determining a surgical strategy. Methods We searched 3 electronic databases for studies discussing the correlation between CL and spine sagittal alignment in patients with AIS. Studies reported from the inception of the database to June 2019 were retrieved without any language restrictions. Summary correlation coefficient (r) values were extracted from each study, and 95% confidence intervals (CIs) were calculated. In addition, we conducted subgroup analyses in different curve type subgroups with at least 2 studies. Results Ten relevant studies involving 539 patients were evaluated in this meta-analysis. The Pearson correlation (r) for CL and the T1 slope was –0.69; (95% CI, –0.79 to –0.54). The fixed-effects summary correlation between CL and thoracic kyphosis in patients was moderate (r = –0.40; 95% CI, –0.48 to –0.31). In addition, the fixed-effects summary correlations between CL and lumbar lordosis (r = 0.19; 95% CI, 0.07–0.30), pelvic incidence (r = –0.08; 95% CI, –0.20 to 0.04), pelvic tilt (r = –0.06; 95% CI, –0.18 to 0.06), and sacral slope (r = –0.06; 95% CI, –0.18 to 0.06) in patients were weak. Conclusions There is a strong negative correlation between CL and the T1 slope in patients with AIS. Given the lack of robust clinical evidence, these findings warrant verification by large prospective registries and randomized trials with long follow-up periods.

Objective To evaluate the feasibility, success rate, and safety of endovascular revascularization of nonacute symptomatic proximal extracranial vertebral artery occlusion (PEVAO). Methods In a retrospective, single-center study, we analyzed clinical and imaging data from consecutive patients with PEVAO who underwent endovascular revascularization from June 2011 to March 2018. Results The study enrolled 23 patients (mean age, 59 years; range, 42–77 years; 17 men). The rate of successful technical revascularization was 91.3% (n = 21), and the rate of complications was 4.3% (n = 1). At 3-month follow-up, the patients with successful endovascular revascularization of nonacute symptomatic PEVAO did not present any neurologic symptoms and computed tomography angiography did not show restenosis of the stent. Conclusions Endovascular revascularization of nonacute symptomatic PEVAO is feasible and associated with a high rate of procedural success and low rate of procedural complications. A large, multicenter, randomized study is warranted to confirm the findings.

Background A paucity of randomized trials have compared prophylactic dose of unfractionated heparin (UFH) versus low-molecular-weight heparin (LMWH) for the prevention of venous thromboembolic events in spinal surgery. Our objective was to determine the most prevalent chemoprophylactic techniques in spine surgery. Methods The Accreditation Council for Graduate Medical Education was queried for all neurosurgical residency programs, which were subsequently sent an electronic survey about prophylactic UFH versus LMWH in spine surgery for (1) degenerative/deformity, (2) traumatic, and (3) neoplastic pathologies. Results Of 69 unique responding residencies, the first dose of chemoprophylaxis for degenerative/deformity spinal disease started most commonly on postoperative day (POD) 1 in 75.3% of neurosurgery programs, followed by POD 2 in 10.1% of programs, POD 0 (same day of surgery) in 8.7% of programs, POD 3 in 1.4% of programs, and morning of surgery in 1.4% of programs. Choice of postoperative chemoprophylaxis did not differ statistically significantly between UFH versus LMWH: 56.5% versus 36.2% in degenerative/deformity pathologies (P = 0.080) and 50.7% versus 43.4% in traumatic pathologies (P = 0.535). Three programs (4.3%) in both the degenerative/deformity and trauma groups documented no chemoprophylaxis. Neoplastic pathologies saw a statistically significantly higher proportion of prophylactic UFH (60.8%) compared with prophylactic LMWH (36.2%) (P = 0.037). One program (1.4%) in the neoplastic group did not utilize chemoprophylaxis. Two institutions (2.8%) in the degenerative/deformity cohort and 1 institution (1.4%) in the trauma and cancer cohorts reported “other”. Conclusions Prophylactic UFH was statistically more common than LMWH in neoplastic spinal surgery, but not in the degenerative/deformity and trauma groups (cohorts). Further trials are warranted.

Background Traumatic brain injury (TBI) is a common public health problem. The optimal timing of fracture fixation in patients with TBI has remained controversial. We conducted a meta-analysis to quantitatively discuss the effects of fixation timing on the prognosis of patients with extremity fracture and concomitant TBI. Methods A systematic search was performed in PubMed, EMBASE, the Cochrane Library and 4 Chinese databases from the inception date to May 19, 2019. Randomized controlled trials and cohort studies comparing early and late fracture fixation in adults with TBI concomitant with extremity fractures were selected. The risk ratio (RR) and standardized mean difference were calculated. Results A total of 14 cohort studies involving 1046 patients fulfilled our criteria. No statistically significant association was found between fixation timing and mortality rate (RR, 1.34; 95% confidence interval [CI], 0.89–2.01). No significant association was found between fracture fixation timing and the incidence of death among the patients with severe TBI (RR, 1.82; 95% CI, 0.50–6.66), moderate or more serious TBI (RR, 3.78; 95% CI, 0.53–26.78), and unrestricted TBI type (RR, 0.80; 95% CI, 0.38–1.68). No significant association was found between fracture fixation timing and neurologic complications (RR, 0.71; 95% CI, 0.45–1.11). When the cutoff for fixation timing was set at 14 days, the incidence of nonunion or malunion in the earlier fixation group was lower than that in the later fixation group (RR, 0.39; 95% CI, 0.17–0.91). Conclusion Late fracture fixation conducted >14 days after injury was associated with nonunion or malunion. Fixation performed within 24 hours did not influence mortality or adverse neurologic events.

Background Several independent randomized controlled trials have shown superior efficacy of mechanical thrombectomy (MT) for management of acute ischemic stroke (AIS). However, elderly patients have been underrepresented or excluded in these trials. The aim of this study was to investigate the feasibility and safety of MT in patients with AIS ≥90 years old. Methods A retrospective review was performed of patients ≥90 years old presenting with AIS who underwent MT between 2010 and 2018. Results Of 453 patients with AIS, 5.74% (n = 26) were ≥90 years old, and 69.32% (n = 314) were 60–89 years old. Of baseline characteristics between both groups, there was a significant difference in age, sex, body mass index, smoking, hyperlipidemia, atrial fibrillation, and diabetes mellitus. Mean National Institutes of Health Stroke Scale score on admission was higher in the nonagenarians (17 vs. 15). Similar proportions of both groups received tissue plasminogen activator, 57.69% (n = 15) versus 42.68% (n = 134), P = 0.14). There was no difference in periprocedural and postprocedural complications, good Thrombolysis In Cerebral Infarction scores (88.46% [n = 23] vs. 87.58% [n = 275], P = 1.00), good modified Rankin Scale scores (34.62% [n = 4] vs. 49.36% [n = 155], P = 0.40), or mortality (11.54% [n = 3] vs. 13.06% [n = 41], P = 0.82). Conclusions Age is a factor that affects functional outcome following MT. Advancements in catheter techniques, technical experience, and great outcomes with MT allow for pushing the boundaries to consider age as one factor, rather than an exclusion criterion. Our results show that MT is safe and feasible in nonagenarians.

Decompressive hemicraniectomy (DHC) is widely applied for patients with traumatic brain injury (TBI). Although previous studies have indicated that DHC can lead to similar or worse outcomes compared with medical treatment (MT) in patients with TBI, recent trials have suggested the benefit of DHC for neurologic function recovery. Therefore, we performed this meta-analysis to assess the efficacy and functional outcomes of DHC in patients with TBI.In accordance with PRISMA guidelines, we searched English and Chinese databases to identify relevant randomized controlled trials (RCTs) reporting DHC for TBI. The outcomes measures included mortality, favorable outcome, unfavorable outcome, postoperative intracranial pressure (ICP), adverse events with hematoma, and hospital stay.Seven RCTs with a total of 779 patients with TBI were included in this meta-analysis. Compared with the MT group, the DHC group demonstrated significantly lower rates of mortality (P0.00001), postoperative ICP (P0.00001), and postoperative hematoma (P = 0.01), and significantly shorter hospital length of stay (P = 0.02). However, the rate of unfavorable outcomes was higher in the DHC group compared with the MT group (P = 0.0001).Our results indicate that DHC could be effective in reducing the mortality rate, incidence of ICP, and hospital length of stay in patients with TBI. However, the proportion of patients surviving with unfavorable outcomes was significantly higher in the DHC group compared with the MT group. Despite the limitations of the meta-analysis, our findings target extremely important topic and provide important evidence to facilitate clinical decision making.

Background Patients undergoing spine surgery may experience substantial postoperative pain. Objective The aim of this Systematic Review is to examine the clinical efficacy of a newly introduced regional Anesthetic block titled ‘Erector Spinae Plane Block’ (ESPB) for adults undergoing posterior spine surgeries. Methods A formal systematic database search was conducted in PubMed, Ovid Medline, Embase, Cochrane library, and Google Scholar for randomized controlled trials (RCTs) comparing ESPB with control or placebo. Results Our Systematic Review demonstrated a reduction of postoperative pain and opioid consumption in patients who had ESPB compared to control groups for lumbar spine surgery. However, the effect obtained revealed only a short-term benefit. Conclusion Current evidence is insufficient to support the widespread use of ESPB for spine surgery. More studies are warranted to confirm or refute its role in clinical practice.

Background Enhanced Recovery after Surgery (ERAS) pathways are increasingly being integrated in neurosurgical patient management. The full extent of ERAS in cranial surgery is not well studied. We performed a systematic review examining ERAS in cranial surgery patients to 1) identify the extent to which ERAS is integrated in cranial neurosurgical procedures and 2) assess effectiveness of ERAS interventions for patients undergoing these procedures. Methods A systematic review of MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, Scopus, PsychInfo, and Google Scholar was conducted according to PRISMA guidelines (CRD42020197187). Studies eligible for inclusion assessed patients undergoing any cranial surgical procedure using an ERAS or ERAS-like pathway, defined by ≥2 ERAS protocol elements per the ERAS Society’s RECOvER Checklist and the recommendations of Hagan et al. 2016 (not including patient education, criteria for discharge, or tracking of postdischarge outcomes). Results Nine studies were included in qualitative synthesis, 2 of which were randomized controlled trials. All studies showed a moderate risk of bias. The most common ERAS elements used were screening and/or optimization and formal discharge criteria. The least common ERAS elements used were fasting/carbohydrate loading and antithrombotic prophylaxis. Complication rates were similar in studies comparing ERAS with non-ERAS groups. ERAS interventions were associated with reduced length of stay, with comparable and/or improved patient satisfaction. Conclusions ERAS is a safe and potentially favorable perioperative pathway for select patients undergoing cranial surgery. Future studies of ERAS in cranial surgery patients should emphasize postoperative optimizations and patient-reported outcome measures as key features.

Objective According to A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) conservative treatment seems to be superior to any intervention for unruptured brain arteriovenous malformations (AVM). This study aims to evaluate safety and efficacy of upfront and repeated Gamma-Knife Radiosurgery (GKRS) in patients harbouring small AVM fulfilling the inclusion criteria of ARUBA. Methods A retrospective study was conducted to evaluate outcomes of unruptured naive brain AVM with a volume ⩽ 5cc eligible to ARUBA treated by GKRS with at least 3 years of follow-up. Results From 1992 to 2014, 249 patients were fulfilling the inclusion criteria of this study. The median age was 36 years [18-78]. The median treated volume of the nidus was 1.3 cc [0.4-5] and 63% of the AVM were in eloquent areas. Radiosurgery Based AVM score was 1-1.8 (76%), the Spetzler-Martin grade was II-III (73%), and the Virginia Radiosurgery AVM scale was ≤1point (75%). The overall AVM obliteration rate was 77.1% after up to 3 GKRS sessions. The median dose at the margin was 24 Gy [15-25] and the median follow-up was 45 months [36–205]. Eight patients (3.2%) experienced hemorrhage after GKRS, corresponding to a post-GKRS hemorrhage annual rate of 1.03%. Permanent symptomatic radio-induced changes rate was 2% (4 increased seizures, 1 neurological deficit). Conclusion The very low toxicity rate and the high occlusion rate are preaching in favor of upfront and repeated GKRS for unruptured small AVM (≤5cc).

This study was designed to help elucidate the benefits and advantages of vertebroplasty combined with zoledronic acid (ZOL) versus vertebroplasty alone, to provide clinical recommendations for the treatment of osteoporotic vertebral compression fractures (OVCFs) considering the current best-available evidence.We comprehensively searched PubMed, Embase, Web of Science, and the Cochrane Library and performed a systematic review and cumulative meta-analysis of all randomized controlled trials and retrospective comparative studies assessing these important indexes of 2 methods using Review Manager 5.4.Four randomized controlled trials and 4 retrospective studies including 2335 cases were identified. Vertebroplasty combined with ZOL was associated with benefits from decreased pain (weighted mean difference [WMD] -0.43; 95% confidence interval [CI] -0.59 to -0.27; P0.05), increased function (WMD -4.94; 95% CI -6.13 to -3.75; P0.05), increased BMD of the vertebral body(WMD 0.85; 95% CI 0.30-1.40; P0.05) and of the proximal femoral neck (WMD 0.14; 95% CI 0.08-0.21; P0.05), fewer markers of bone metabolism (N-terminal molecular fragment: WMD -4.82; 95% CI -6.08 to -3.55; P0.05; procollagen type I N-terminal propeptide: WMD -17.31; 95% CI -18.04 to -16.58; P0.05; beta collagen degradation product: WMD -0.27; 95% CI -0.35 to -0.19; P0.05), and lower rate of refracture (1.54% and 12.6%; odds ratio 0.17; 95% CI 0.08-0.36; P0.05). Patients in the vertebroplasty combined with ZOL group had greater vertebral body height (WMD 2.17; 95% CI 0.72-3.62; P0.05) than in the vertebroplasty group, but no differences on Cobb angle were observed (WMD -1.18; 95% CI -2.47 to 0.10; P0.05).Vertebroplasty combined with ZOL was superior to vertebroplasty alone in terms of BMD, bone metabolism makers, refracture rate, pain and function.

Background Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH. Methods A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH. Results Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63–56.71), decreasing mortality (OR, 0.08; 95% CrI, 0–0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057–0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97–6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12–1.15). Fasudil (OR, 0.16; 95% CrI, 0.03–0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057–1.0) in preventing delayed ischemic neurologic deficits. Conclusions Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.

Objective We sought to compare the angiographic and clinical outcomes of drug-coated balloon (DCB) with distal embolic protection devices (EPDs) versus bare metal stent (BMS) without EPD in the treatment of symptomatic vertebral artery origin stenosis (VAOS). Methods Between January 2017 and December 2018, a prospective randomized trial was conducted involving 95 patients with symptomatic VAOS randomly assigned to treatment with DCB + EPD (n = 49) or BMS without EPD (n = 46). Target vessel restenosis (RS) >50% detected by computed tomography angiography was the primary endpoint. Technical success, clinical success, and signal intensity abnormalities on diffusion-weighted imaging within 3 days after operation were compared. Results The 30-day technical success rate was 93.9% for DCB group versus 95.7% for the BMS group (P = 0.094). Diffusion-weighted imaging within 3 days postoperative showed asymptomatic embolization in 2 (4.1%) patients in the DCB group and 9 (19.6%) patients in the BMS group (P = 0.004). At a mean 16-month follow-up, the clinical success rate was 89.8% for the DCB group versus 91.3% (42/46) for the BMS group (P = 0.125). The RS was seen in 5/49 (10.2%) in the DCB group and 6/46 (13.0%) in the BMS group (P = 0.082). Target vessel revascularization was performed in 4 (8.7%) BMS group versus 3 (6.1%) in the DCB group (P = 0.091). Conclusions DCB with EPD in the treatment of symptomatic VAOS is technically feasible and safe and significantly reduced thromboembolic events on imaging when compared with BMS without EPD. There was no significant difference between the 2 groups in the rate of RS during 12 months after surgery.

This study aimed to evaluate the superiority of open-door versus French-door posterior cervical laminoplasty in the treatment of multisegmental cervical spondylotic myelopathy by comparing the intraoperative parameters and clinical and radiologic outcomes of these 2 procedures. PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, the Wanfang database, the Weipu database, and China Biology Medicine disk were searched. Articles were retrieved from database establishment through May 22, 2020. Data analysis was carried out on the retrieved articles using RevMan 5.3 software. This meta-analysis included 14 studies involving 1010 patients, among which 6 were randomized controlled trials and 8 were retrospective analyses. Comparing the open-door and French-door groups, no statistically significant differences were found in operative time (weighted mean difference [WMD] = −4.47, 95% CI [−17.85, 8.92], P = 0.51), postoperative Japanese Orthopaedic Association score (WMD= −0.24, 95% CI [−0.87, 0.38], P = 0.45), recovery rate (WMD= −0.58, 95% CI [−3.61, 2.45], P = 0.71), postoperative cervical lordosis (WMD= −0.15, 95% CI [−1.93, 1.63], P = 0.87), cervical range of motion (WMD = −3.04, 95% CI [−8.68, 2.59], P = 0.29), sagittal diameter of the spinal canal (WMD = −0.24, 95% CI [−0.54, 0.07], P = 0.13), incidence of C5 palsy (OR = 1.78, 95% CI [0.64, 4.93], P = 0.27), or incidence of cerebrospinal fluid leakage (OR = 1.51, 95% CI [0.48, 4.71], P = 0.48). However, the French-door group was associated with less intraoperative bleeding (WMD = 54.96, 95% CI [21.37, 88.55], P = 0.001) and a lower incidence of axial symptoms (OR = 2.50, 95% CI [1.32, 4.72], P = 0.005). This analysis suggests that both methods can achieve good postoperative outcomes. However, less intraoperative bleeding and a lower incidence of postoperative axial symptoms were found in the French-door group. This requires further validation and investigation in larger sample-size and well-designed randomized controlled studies.

Objective To determine the effect of vitamin D supplementation on postoperative pain and analgesic requirement in brain tumor surgery. Methods A total of 60 patients with vitamin D serum levels ≤20 ng/dL were randomly assigned to 2 groups equally. The study group (n = 30) received intramuscular injection of 300,000 IU vitamin D before surgery. Results Preoperative serum level of vitamin D was 15.9 ± 3.8 ng/dL and 14.5 ± 3.6 ng/dL in the study and control groups, respectively (P = 0.13). Serum level of vitamin D on day 5 of surgery was 22.5 ± 4.3 and 13.7 ± 3.8 in the study and control groups, respectively (P 4 on the first postoperative day, which decreased with time. The median (interquartile range) of the visual analogue scale score during the 3 postoperative days was 3 (5), 3 (5), 1 (3), and 5 (7), 2 (5), 1 (3) in the study and control groups, respectively, with no significant difference. There was no difference in analgesic consumption between the 2 groups. Analysis through the generalized estimating equation model indicated that patients who had received vitamin D for a longer time before the operative time had an insignificantly less pain score. Conclusions On the basis of the study results, one half of our patients reported moderate-to-severe pain scores on the first day after surgery. The pain in the study group was insignificantly less than that in the control group, but it seems that chronic high level of vitamin D may lead to promising results.

Objective Endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) are 2 surgical methods used for the treatment of obstructive hydrocephalus. However, the efficacy and safety of these 2 procedures are unknown. Therefore we conducted a meta-analysis to compare the safety and efficiency of ETV and VPS in patients with obstructive hydrocephalus. Methods In January 2019, a comprehensive search strategy of 3 electronic databases was initiated. A systematic search from database inception to December 30, 2018, on clinical outcome, safety, and efficiency of ETV and VPS in the treatment of obstructive hydrocephalus was conducted. The following electronic databases were searched: PubMed, Embase, and Cochrane Library for related randomized controlled trials (RCTs). Main outcomes included postoperative hematoma, postoperative infection, postoperative cerebrospinal fluid leakage, blockage rate, and mortality. Results Of the 546 studies identified, 4 RCTs involving 250 patients met our inclusion criteria. The pooled results show that ETV was associated with lower incidence of postoperative infection (risk ratio [RR] 0.09, 95% confidence interval [CI]: 0.02–0.32, P = 0.0002); postoperative hematoma (RR 0.26, 95% CI: 0.08–0.88, P = 0.03); and blockage rate (RR 0.28, 95% CI: 0.13–0.60, P = 0.001) compared with VPS. Compared with VPS, ETV had no significant effect on incidence rate of postoperative cerebrospinal fluid leakage (RR 2.00, 95% CI: 0.30–13.16, P = 0.47) and mortality rates (RR 0.19, 95% CI: 0.03–1.09, P = 0.06), but there have been no deaths in patients treated with ETV. Conclusions On the basis of the meta-analysis of RCTs evaluating ETV and VPS, the incidence of complications and mortality was higher with the VPS procedure, and therefore greater benefits can be achieved using ETV.

Background Preoperative embolization (POE) of meningioma has been established to facilitate surgical resection, which may reduce intraoperative blood loss and surgical time. However, no consensus has been achieved in meningioma treatment and no meta-analysis has been conducted. The purpose of this study was to perform a systematic review and meta-analysis and provide evidence of the efficacy of meningioma treatment with POE and direct surgery. Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A systematic search was performed using PubMed and EMBASE. Meta-analysis was performed using the risk ratio of overall complication, mean difference (MD) of blood loss, and surgical time. The I2 statistic was used to assess the heterogeneity. Results Eight studies (1 randomized controlled trial and 7 non-randomized controlled trials) were included, in which 510 patients met the inclusion criteria. We found that preoperative embolization for patients with meningioma did not increase the overall complication rate (risk ratio = 0.92, 95% confidence interval [CI] 0.61–1.38) and can significantly reduce intraoperative blood loss (MD = –65.10, 95% CI –124.76 to –20.82) and surgical time (MD = –38.48, 95% CI –64.03 to –12.93) compared with the control patients. No significant publication bias was observed. Conclusions This meta-analysis supports the hypothesis that POE of meningioma is a useful adjunct in meningioma treatment. This technique helps reduce blood loss and surgical time during meningioma resection.

The purpose of this study was to assess the immediate postoperative clinical outcomes and perform a preliminary analysis of the effectiveness of biportal endoscopic approaches to lumbar decompressive laminectomy in the treatment of lumbar spinal stenosis.All participants (64 patients) were randomly assigned in a 1:1 ratio to either the biportal endoscopic lumbar decompressive laminectomy (BE-D) group or the mini-open microscopic lumbar decompressive laminectomy (MI-D) group. Early postoperative outcomes were evaluated using clinical and surgical technique-related outcomes. The visual analog scale (VAS) pain score was measured at 6 time points after surgery (at 4, 8, 16, 24, and 48 hours and 2 weeks). Surgical technique-related outcomes were also analyzed.There were no significant differences in the preoperative demographics between the 2 groups. The VAS pain score from 8 to 48 hours (P0.05) was significantly lower in the BE-D group than in the MI-D group. Moreover, the total amount of fentanyl usage was higher in the MI-D group than in the BE-D group after surgery (P = 0.026). The length of hospital stay was lower in the BE-D group than in the MI-D group (P = 0.048). The operative time and creatinine phosphokinase level were not significantly different between the groups (P0.05). Postoperative drainage was significantly higher in the BE-D group than in the MI-D group.BE-D was associated with rapid pain recovery, low fentanyl usage, and early discharge after surgery, but its other benefits have not yet been shown.

To observe the efficacy of intravenous, topical, and combined application of tranexamic acid (TXA) in patients with thoracolumbar fracture fixed with percutaneous pedicle screw, and to identify the optimal application method of TXA.A total of 181 patients with thoracolumbar fracture treated with percutaneous pedicle screw fixation were enrolled in this randomized controlled trial and were randomly classified into 3 groups, including group A (intravenous group), group B (topical group), and group C (combined group). The total blood loss (TBL), hidden blood loss (HBL), intraoperative blood loss (IBL), preoperative D-dimer, postoperative D-dimer, incidence of deep vein thrombosis (DVT), and incidence of other complications were compared and analyzed among the 3 groups.TBL, HBL, and IBL in the topical group 24 hours after operation were higher (P0.05) than those in the intravenous group and combined group, whereas the difference between the intravenous group and combined group was not statistically significant. Meanwhile, there was no statistically significant difference in operation time, preoperative D-dimer, and postoperative D-dimer among the 3 groups (P0.05), but D-dimer in all groups at 72 hours after surgery was higher than that before surgery. No DVT or other complication was observed in the patients.Preoperative intravenous drip of TXA can remarkably reduce intraoperative HBL and IBL in patients with thoracolumbar fracture fixed with percutaneous pedicle screw. Nonetheless, intraoperative topical application of TXA before wound closure is not recommended.