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Study design Bibliometric analysis. Objective To identify, and summarize the key findings of, the top 100 most highly cited works published in spinal disorder topic-specific journals. Summary of background data There is an abundance of published articles pertaining to spine surgery and spinal disorders. The number of citations a work receives provides a useful measure of its scientific impact. An understanding of the most cited works in spine surgery can identify literature that surgeons and researchers should be familiar with, point to the most active areas of research, inform the design of educational curricula, and help guide future research efforts. Methods Journals relating to spinal disorders were identified using the Journal Citation Reports database. We then searched the Web of Science database for articles appearing in each of these journals. The top 100 most cited works were selected for analysis. Results The top 100 most cited articles appeared in seven of eight journals dedicated to spinal disorders, with 84 in Spine and seven in the European Spine Journal. The citation count for individual articles ranged from 343 to 1949. Most works (73) were published between 1990 and 2004. The greatest number of articles (22) focused on low back pain, followed by biomechanics (13), degenerative disc disease (12), and lumbar spinal stenosis/lumbar fusion (9). With regard to study design, laboratory investigations were the most common (12), followed by guideline documents (11), reviews (10), and retrospective cohort studies (10). Conclusion The most cited works in spinal disorder journals are guidelines for low back pain, descriptions of quality of life (QOL) metrics, or laboratory investigations into spinal biomechanics. A gap exists for work relating to neck pain or cervical spinal pathology (e.g., cervical myelopathy), representing opportunity for future work. Time of publication, topic of study, study design, and journal are possible determinants of likelihood of citation. Level of evidence N/A.

Background The rates of clinical and radiographic progression and the need for neurosurgical intervention in patients with isolated traumatic subarachnoid hemorrhage (itSAH) after mild traumatic brain injury (Glasgow Coma Scale score, 13-15) has not been well established.The aim of this work was to review the evidence regarding patient outcomes after mild traumatic brain injury with itSAH. Methods Two authors independently extracted the data according to a predefined protocol. The proportions of patients who had the outcomes of interest were pooled using random-effects model. The quality of included studies was assessed using the methodological index for nonrandomized studies scale. Results Thirteen studies reporting on 15,327 patients met inclusion criteria, and outcomes were pooled where available. No patient required neurosurgical intervention on presentation to hospital, and the incidence of need for eventual neurosurgical intervention was 0.0017% (95% confidence interval [CI], 0-0.39%). Moreover, the pooled analyses for all patients with available data showed an incidence of 5.76% (95% CI, 1.18-12.94%) for radiographic progression, 0.75% (95% CI, 0-2.39%) for neurologic deterioration, and 0.60% (95% CI, 0.09-1.41%) for mortality. Only one patient had died due to neurological injury. Conclusions These patients experience very low rates of radiographic progression and neurologic deterioration and rarely require neurosurgical intervention or die due to neurological injury. Level of evidence Meta-analysis, level III.

Background Endoscopic third ventriculostomy (ETV) is a safe and effective treatment for hydrocephalus. An entry point located 4 cm anterior to the coronal suture, 3 cm anterior to Kocher point, and approximately 9 cm from the pupil at the midpupillary line has been used successfully for the last 20 years in our center. We aimed to evaluate this alternative anterior entry point routinely used for ETV, with or without concurrent endoscopic biopsy. Methods Patients undergoing this proposed entry point were examined to evaluate its safety and efficacy. Factors such as patients' age, sex, hydrocephalus etiology, tumor location and pathology, and complication rate were examined through regression analyses to evaluate their impact on tumor biopsy and ETV success rates, and the need for subsequent ventricular shunting. Results A total of 131 patients were included in the study. ETV was successful in 125 (95.4%) patients. Of these, 26 (19.8%) patients required a biopsy, which was successful in 21 (80.8%) cases. A complication was observed in 10 (7.6%) patients, with a trend toward complications occurring after ETV failure. There was no association between ETV success rate and patients' age (P = 0.5) or sex (P = 0.99). Conclusions The anterior entry point is a safe and effective method for ETV, especially when considering concurrent ventricular tumor biopsy. This entry point may be considered as a more minimally invasive procedure when using rigid endoscopy and may also eliminate the need for a flexible scope.

Background and importance Myxoid liposarcoma is not an uncommon form of sarcoma. However, it usually affects the lower extremity long bones. Scapular involvement is extremely rare, as is a metastasis to the parasellar region. We present a case of liposarcoma of the skull base originating in the scapular region and metastasizing to the sellar and parasellar regions and provide a review of the pertinent literature. Clinical presentation A 43-year-old female patient diagnosed with left scapular myxoid liposarcoma was treated with surgical resection. She had clear resection margins and was treated pre- and postoperatively with radiotherapy to the region. She remained asymptomatic for 2 years following surgery, after which she abruptly developed diplopia with right lateral gaze. There were no symptoms of raised intracranial pressure or impaired vision. Her examination was normal apart from complete right sixth nerve palsy. Imaging studies of the brain showed a large mass in the clivus eroding into the floor of the sella, encircling the right internal carotid artery in the cavernous sinus. The mass also displaced the sellar contents superiorly. An endonasal, endoscopic skull base approach was undertaken, and a subtotal resection was performed in an effort to avoid multiple cranial nerve pareses. Conclusion Our literature search revealed that this case report is the first to document liposarcoma metastasis to the skull base originating from the scapular region. Subtotal surgical resection resulted in minimal improvement of the patient's sixth nerve palsy. Postoperative radiation was undertaken. A multidisciplinary approach on an individual patient basis is recommended.

Purpose: Older patients with glioblastoma (GBM) are underrepresented in clinical trials. Several abbreviated and standard chemoradiotherapy regimens are advocated with no consensus on the optimal approach. Our objective was to quantitatively evaluate which of these regimens would provide the most favorable survival outcomes in older patients with GBM using a network meta-analysis. Experimental Design: MEDLINE, Embase, Google Scholar, and the Cochrane Library were searched. Patients >60 years of age with histologically confirmed GBM were included. Primary outcome of interest was the pooled HR from randomized controlled trials (RCTs). Secondary outcomes of interest included pooled HR from studies controlling for MGMT promoter methylation status, and safety. Results: Fourteen studies, including 5 RCTs, reporting 4,561 patients were included. Using highest quality data from RCTs, our network-based approach demonstrated that standard radiotherapy (SRT) and temozolomide (TMZ) provided similar survival benefit when compared with hypofractionated radiotherapy (HRT) and TMZ [HR = 0.90; 95% confidence interval (CI), 0.43–1.87], TMZ alone (HR 1.25; 95% CI, 0.69–2.26), HRT alone (HR = 1.34; 95% CI, 0.73–2.45), or SRT alone (HR = 1.43; 95% CI, 0.87–2.36). HRT-TMZ had the highest probability (85%) of improving survival in older patients with GBM followed by SRT-TMZ (72%). Pooled analysis of trials controlling for MGMT promoter methylation status demonstrated that TMZ monotherapy confers similar survival benefit to combined chemoradiotherapy. Conclusions: Statistical comparisons using a network approach demonstrates that the common treatment regimens for older patients with GBM in previous RCTs confer similar survival benefits. Adjustments for MGMT promoter methylation status demonstrated that radiotherapy alone was inferior to TMZ-based approaches. Head-to-head comparison of TMZ monotherapy to combined TMZ and radiation is warranted.

The present study aims to determine the tumor-related, clinical, and demographic factors associated with extent of resection (EOR) and post-operative outcomes in JPA patients.All patients with JPA, identified from a single-center brain tumour data base, were included in this retrospective analysis. Pre-operative MRI scans were reviewed by a single neurosurgeon blinded to the EOR. JPA cases that exhibited no residual tumor post-operatively were assigned to the GTR group, all other tumors were assigned to theGTR group. Tumor-related, clinical and demographic variables as well as perioperative morbidities were compared between both groups.Of the 28 patients included, 15 had a GTR (46% male; median age: 7.5 years; range: 1.16-14.9) and 13 hadGTR (69.2% male; median age: 10.6 years; range: 0.66-17.68). Tumor location reached statistical significance, as there were significantly more cerebellar tumors in the GTR group (86.7%) compared to theGTR group (38.5%) (p = 0.016). GTR cases had a significantly longer average follow-up interval (6.6 months) thanGTR cases (4.5 months) (p = 0.031). All demographic variables, clinical variables and tumor-related factors showed no significant differences between the two groups. There were no differences between GTR andGTR cases in terms of perioperative outcomes.This study shows other than location of the lesion in the cerebellum, demographic, clinical and tumor-related variables are not associated with EOR in children with JPA. GTR was associated with an extended follow-up interval but not with increased perioperative morbidities compared to those withGTR.

This meta-analysis of 71 studies examines the accuracy of bedside optic nerve ultrasonography for diagnosing increased intracranial pressure in persons with either traumatic or nontraumatic brain i...

While studies have demonstrated that decompressive craniectomy after stroke or TBI improves mortality, there is much controversy regarding when decompressive craniectomy is optimally performed. The goal of this paper is to synthesize the data regarding timing of craniectomy for malignant stroke and traumatic brain injury (TBI) based on studied time windows and clinical correlates of herniation. In stroke patients, evidence supports that early decompression performed within 24 h or before clinical signs of herniation may improve overall mortality and functional outcomes. In adult TBI patients, published results demonstrate that early decompressive craniectomy within 24 h of injury may reduce mortality and improve functional outcomes when compared to late decompressive craniectomy. In contrast to the stroke data, preliminary TBI data have demonstrated that decompressive craniectomy after radiographic signs of herniation may still lead to improved functional outcomes compared to medical management. In pediatric TBI patients, there is also evidence for better functional outcomes when treated with decompressive craniectomy, regardless of timing. More high quality data are needed, particularly that which incorporates a broader set of metrics into decision-making surrounding cranial decompression. In particular, advanced neuromonitoring and imaging technologies may be useful adjuncts in determining the optimal time for decompression in appropriate patients.

Glioblastoma (GBM) is the most common and fatal primary adult brain tumor. To date, various promising chemotherapeutic regimens have been trialed for use in GBM; however, temozolomide (TMZ) therapy remains the only US Food and Drug Administration-approved first-line chemotherapeutic option for newly diagnosed GBM. Despite maximal therapy with surgery and combined concurrent chemoradiation and adjuvant TMZ therapy, the median overall survival remains approximately 14 months. Given the failure of conventional chemotherapeutic strategies in GBM, there has been renewed interest in the role of immunotherapy in GBM. Dendritic cells are immune antigen-presenting cells that play a role in both the innate and adaptive immune system, thereby making them prime vehicles for immunotherapy via dendritic cell vaccinations (DCVs) in various cancers. There is great enthusiasm surrounding the use of DCVs for GBM with multiple ongoing trials. In this review, we comprehensively summarize the safety, efficacy, and quality of life results from 33 trials reporting on DCV for high-grade gliomas.

Background The role of the extent of surgical resection (EOR) in clinical outcomes for patients with low-grade glioma requires further examination. The goal of the present study was to evaluate the association between variable degrees of EOR and clinical outcomes for patients with low-grade glioma. Methods We conducted a systematic review and meta-analysis and searched databases for reports of low-grade glioma EOR. Eligible studies compared patient outcomes, including ≥2 categories of EOR (biopsy, resection of any extent, subtotal resection [STR], or gross total resection [GTR]). Treatment effects were evaluated using pooled estimates, mean differences, or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) using random effects modeling. Results Our literature search yielded 60 studies with 13,289 patients. Pooled estimates of overall survival (OS) showed an increase from 3.79 years in the biopsy group to 6.68 years in STR to 10.65 years in GTR. OS was favorable with resection of any extent compared with (mean difference, 3.24; 95% CI, 0.64–5.84; P = 0.015). Pooled estimates of seizure control showed an improvement from 47.8% with biopsy to 54.2% with STR and 81.0% with GTR. Compared with STR, GTR delayed malignant transformation (RR, 0.43; 95% CI, 0.20–0.93; P = 0.032), without increasing postoperative mortality (RR, 0.38; 95% CI, 0.07–1.97; P = 0.250) or morbidity (RR, 1.22; 95% CI, 0.65–2.28; P = 0.540). Conclusion Among patients with low-grade gliomas, greater degrees of safe EOR were associated with longer OS and progression-free survival, better seizure control, and delayed malignant transformation, without increasing mortality or morbidity.

BACKGROUND Patients with mild degenerative cervical myelopathy (DCM) represent a heterogeneous population, and indications for surgical decompression remain controversial. OBJECTIVE To dissociate patient phenotypes within the broader population of mild DCM associated with degree of impairment in baseline quality of life (QOL) and surgical outcomes. METHODS This was a post hoc analysis of patients with mild DCM (modified Japanese Orthopedic Association [mJOA] 15-17) enrolled in the AOSpine CSM-NA/CSM-I studies. A k-means clustering algorithm was applied to baseline QOL (Short Form-36 [SF-36]) scores to separate patients into 2 clusters. Baseline variables and surgical outcomes (change in SF-36 scores at 1 yr) were compared between clusters. A k-nearest neighbors (kNN) algorithm was used to evaluate the ability to classify patients into the 2 clusters by significant baseline clinical variables. RESULTS One hundred eighty-five patients were eligible. Two groups were generated by k-means clustering. Cluster 1 had a greater proportion of females (44% vs 28%, P = .029) and symptoms of neck pain (32% vs 11%, P = .001), gait difficulty (57% vs 40%, P = .025), or weakness (75% vs 59%, P = .041). Although baseline mJOA correlated with neither baseline QOL nor outcomes, cluster 1 was associated with significantly greater improvement in disability (P = .003) and QOL (P

OBJECTIVEThe aim of this study was to describe the current state of epilepsy surgery and establish estimates of seizure outcomes following surgery for medically intractable epilepsy (MIE) in low- and middle-income countries (LMICs).METHODSThe MEDLINE and Embase databases were searched without publication date restriction. This search was supplemented by a manual screen of key epilepsy and neurosurgical journals (January 2005 to December 2016). Studies that reported outcomes for at least 10 patients of any age undergoing surgery for MIE in LMICs over a defined follow-up period were included. A meta-analysis with a random-effects model was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. Pooled estimates of seizure freedom and favorable seizure outcomes following anterior temporal lobectomy with or without amygdalohippocampectomy (ATL ± AH) were reported.RESULTSTwenty studies were selected, of which 16 were from Asian centers. The average age at surgery in all studies was less than 30 years, and the average preoperative duration of epilepsy ranged from 3 to 16.1 years. Mesial temporal sclerosis accounted for 437 of 951 described pathologies, and 1294 of the 1773 procedures were ATL ± AH. Based on 7 studies (646 patients) the pooled seizure freedom estimate following ATL ± AH was 68% (95% CI 55%–82%). Based on 8 studies (1096 patients), the pooled estimate for favorable seizure outcomes was 79% (95% CI 74%–85%).CONCLUSIONSSurgery for MIE in LMICs shows a high percentage of seizure freedom and favorable outcomes. These findings call for a concerted global effort to improve timely access to surgery for MIE patients in these regions, including investments aimed at refining existing and establishing additional centers.

Summary Background Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. Methods In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. Findings We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1–13·3) in the conventional needle group to 4·2% (3·3–5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34–0·47, p I 2 =45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29–0·64; p Interpretation Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. Funding None.

What you need to know Is the needle tip configuration important when performing a lumbar puncture for any indication? A systematic review published in the Lancet in December 2017 suggests that it is. The review found that using atraumatic (pencil-point) lumbar puncture needles instead of conventional lumbar puncture needles reduced the risk of post-dural-puncture headache and of return to hospital for additional pain control.1 This guideline recommendation aims to promptly and transparently translate this evidence to a clinical recommendation, following standards for GRADE methodology and trustworthy guidelines.2 The BMJ Rapid Recommendations panel makes a strong recommendation for the use of atraumatic needles for lumbar puncture in all patients regardless of age (adults and children) or indication instead of conventional needles.34 Box 1 shows the article and evidence linked to this Rapid Recommendation. The main infographic provides an overview of the absolute benefits and harms (although none were present here) of atraumatic needles. Table 1 below shows any evidence that has emerged since the publication of this guideline. Box 1 ### Linked resources for this BMJ Rapid Recommendations clusterRETURN TO TEXT

Summary Background Supplemental oxygen is often administered liberally to acutely ill adults, but the credibility of the evidence for this practice is unclear. We systematically reviewed the efficacy and safety of liberal versus conservative oxygen therapy in acutely ill adults. Methods In the Improving Oxygen Therapy in Acute-illness (IOTA) systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, HealthSTAR, LILACS, PapersFirst, and the WHO International Clinical Trials Registry from inception to Oct 25, 2017, for randomised controlled trials comparing liberal and conservative oxygen therapy in acutely ill adults (aged ≥18 years). Studies limited to patients with chronic respiratory diseases or psychiatric disease, patients on extracorporeal life support, or patients treated with hyperbaric oxygen therapy or elective surgery were excluded. We screened studies and extracted summary estimates independently and in duplicate. We also extracted individual patient-level data from survival curves. The main outcomes were mortality (in-hospital, at 30 days, and at longest follow-up) and morbidity (disability at longest follow-up, risk of hospital-acquired pneumonia, any hospital-acquired infection, and length of hospital stay) assessed by random-effects meta-analyses. We assessed quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO, number CRD42017065697. Findings 25 randomised controlled trials enrolled 16 037 patients with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had emergency surgery. Compared with a conservative oxygen strategy, a liberal oxygen strategy (median baseline saturation of peripheral oxygen [SpO2] across trials, 96% [range 94–99%, IQR 96–98]) increased mortality in-hospital (relative risk [RR] 1·21, 95% CI 1·03–1·43, I2=0%, high quality), at 30 days (RR 1·14, 95% CI 1·01–1·29, I2=0%, high quality), and at longest follow-up (RR 1·10, 95% CI 1·00–1·20, I2=0%, high quality). Morbidity outcomes were similar between groups. Findings were robust to trial sequential, subgroup, and sensitivity analyses. Interpretation In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavourable above an SpO2 range of 94–96%. These results support the conservative administration of oxygen therapy. Funding None.

Purpose: Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients. Methods: We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers. Results: Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies. Conclusions: Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question.

Atlantoaxial procedures have been developed in an effort to ensure solid C1-C2 fusion. However, techniques that involve sublaminar wiring have the potential for neural structure injury. We present the management of a patient who previously underwent Gallie fusion 10 years ago and is presenting with a dislodged titanium wire that has migrated into the medulla oblongata. A 52-year-old female patient known with rheumatoid arthritis presented with truncal ataxia and food regurgitation 10 years after undergoing a C1-C2 Gallie fusion. A computerized tomography (CT) scan revealed that a wire from her Gallie fusion procedure migrated into the medulla oblongata. The patient underwent foramen magnum decompression with C1 bilateral laminectomy, instrumentation, and removal of a migrated wire. Six months later, a CT scan showed that all occipital screws were pulled out. In the revision surgery, new occipital screws were placed with a resultant significant improvement in patient's gait postoperatively. Wire migration as a differential diagnosis should be considered in patients presenting with neurological dysfunction who underwent surgical treatment with sublaminar wire fusion techniques.

Background Nutritional supplementation of omega-3 fatty acids has been proposed to modulate the balance of pro- and anti-inflammatory mediators in sepsis. If proved to improve clinical outcomes in critically ill patients with sepsis, this intervention would be easy to implement. However, the cumulative evidence from several randomized clinical trials (RCTs) remains unclear. Methods We searched the Cochrane Library, MEDLINE, and EMBASE through December 2016 for RCTs on parenteral or enteral omega-3 supplementation in adult critically ill patients diagnosed with sepsis or septic shock. We analysed the included studies for mortality, intensive care unit (ICU) length of stay, and duration of mechanical ventilation, and used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the quality of the evidence for each outcome. Results A total of 17 RCTs enrolling 1239 patients met our inclusion criteria. Omega-3 supplementation compared to no supplementation or placebo had no significant effect on mortality [relative risk (RR) 0.85; 95% confidence interval (CI) 0.71, 1.03; P = 0.10; I 2 = 0%; moderate quality], but significantly reduced ICU length of stay [mean difference (MD) −3.79 days; 95% CI −5.49, −2.09; P

Introduction Lumbar puncture is one of the oldest and most commonly performed procedures in medicine, used to diagnose and treat disease. Headache following lumbar puncture remains a frequent complication, causing significant patient discomfort and often requiring narcotic analgesia or invasive therapy. Needle tip design has been proposed to affect the incidence of headache postlumbar puncture, with pencil-point ‘atraumatic’ needles thought to reduce its incidence in comparison to bevelled ‘traumatic’ needles. Despite this, the use of atraumatic needles and knowledge of their existence remains significantly limited among clinicians. This study will systematically review the evidence on atraumatic lumbar puncture needles and compare them with traumatic needles across a variety of clinical outcomes. Methods and analyses We will include published randomised controlled trials (RCTs), observational studies and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CINAHL, WHO Clinical Trials Database and Cochrane Library databases. We will also implement strategies to search the grey literature. 3 reviewers will thoroughly and independently examine the search results, complete data abstraction and conduct quality assessment. Included RCTs will be assessed using the Cochrane risk of bias assessment tool and eligible observational studies will be examined using the Newcastle-Ottawa Scale. We will examine the outcomes of: headache and its type, intensity, duration and treatment; backache; success rate; hearing disturbance and nerve root irritation. The primary outcome will be the incidence of postdural puncture headache. We will calculate pooled estimates, relative risks for dichotomous outcomes and weighted mean differences for continuous outcomes, with corresponding 95% CIs. Statistical heterogeneity will be measured using Cochran9s Q test and quantified using the I2 statistic. We will also conduct prespecified subgroup and sensitivity analyses to examine if covariates exist and to explore potential heterogeneity. Ethics and dissemination Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on atraumatic needles for lumbar puncture and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. Trial registration number CRD42016047546.

Background Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure. Purpose To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults. Data Sources 13 databases from inception through May 2019, reference lists, and meeting proceedings. Study Selection Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard. Data Extraction 3 reviewers independently abstracted data and performed quality assessment. Data Synthesis Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm. Limitation Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes. Conclusion Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests. Primary Funding Source None. (PROSPERO: CRD42017055485).

Introduction: Elevated intracranial pressure (ICP) is a devastating complication of brain injury, such as traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage, ischemic stroke, and other conditions. Delay to diagnosis and treatment are associated with increased morbidity and mortality. For Emergency Department (ED) physicians, invasive ICP measurement is typically not available. We sought to summarize and compare the accuracy of physical examination, imaging, and ultrasonography of the optic nerve sheath diameter (ONSD) for diagnosis of elevated ICP. Methods: We searched Medline, EMBASE and 4 other databases from inception through August 2018. We included only English studies (randomized controlled trials, cohort and case-control studies). Gold standard was ICP≥20 mmHg on invasive ICP monitoring. Two reviewers independently screened studies and extracted data. We assessed risk of bias using Quality Assessment of Diagnostic Accuracy Studies 2 criteria. Hierarchical Summary Receiver Operating Characteristic model generated summary diagnostic accuracy estimates. Results: We included 37 studies (n = 4,768, kappa = 0.96). Of exam signs, pooled sensitivity and specificity for increased ICP were: mydriasis (28.2% [95% CI: 16.0-44.8], 85.9.0% [95% CI: 74.9-92.5]), motor posturing (54.3% [95% CI: 36.6-71.0], 63.6% [95% CI: 46.5-77.8]) and Glasgow Coma Scale (GCS) ≤8 (75.8% [95% CI: 62.4-85.5], 39.9% [95% CI: 26.9-54.5]). Computed tomography findings: compression of basal cisterns had 85.9% [95% CI: 58.0-96.4] sensitivity and 61.0% [95% CI: 29.1-85.6] specificity; any midline shift had 80.9% [95% CI: 64.3-90.9] sensitivity and 42.7% [95% CI: 24.0-63.7] specificity; midline shift≥1cm had 20.7% [95% CI: 13.0-31.3] sensitivity and 89.2% {95% CI: 77.5-95.2] specificity. Finally, pooled area under the ROC curve describing accuracy for ONSD sonography for ICP was 0.94 (95% CI: 0.91-0.96). Conclusion: The absence of any one physical exam feature (e.g. mydriasis, posturing, or decreased GCS) is not sufficient to rule-out elevated ICP. Significant midline shift is highly suggestive of elevated ICP, but absence of shift does not rule it out. ONSD sonography may be useful in diagnosing elevated ICP. High suspicion of elevated ICP may necessitate treatment and transfer to a centre capable of invasive ICP monitoring.

Study design Systematic review and meta-analysis. Objective To evaluate the clinical and functional outcomes of transection of the C2 roots during C1 lateral mass screw placement for atlantoaxial fixation. Summary of background data Transection of the C2 nerve roots has been recommended during atlantoaxial fixation to facilitate C1 lateral mass screw placement and possibly reduce postoperative occipital neuralgia, although this practice remains controversial. Methods We searched MEDLINE, EMBASE, Web of Science, and the Cochrane Library for studies evaluating the outcomes of C1-2 fixation involving sacrifice of the C2 roots. We calculated transformed proportions with 95% confidence intervals (CI) for the outcomes of occipital neuralgia, numbness, bony fusion, and procedural morbidity. For studies comparing C2 transection with nerve sparing surgery, we performed meta-analyses for the outcomes of occipital neuralgia, occipital numbness, blood loss, and operative time. Results Eight observational studies (N = 393) met eligibility criteria. The rate of postoperative occipital neuralgia among included studies was 0% to 25%; occipital numbness, 6.7% to100%; bony fusion, 96.7% to 100%; and procedural morbidity, 0% to 14.3%. Among comparative studies, C2 transection was associated with a higher rate of occipital numbness [odds ratio (OR) 178.6 (95% CI 26.6 to 1198.4)], lower blood loss [mean difference (MD) -195.3 mL (95% CI -317.7 to -72.8 mL)] and shorter operative times [MD -57.5 mins (95% CI -76.9 to -38.2 mins)] than when the C2 roots were spared. We found no difference in rates of occipital neuralgia [OR 1.44 (95% CI 0.45 to 4.68)]. Conclusion Transection of the C2 nerve roots appears to be a viable, safe option when undertaking placement of C1 lateral mass screws. The procedure is associated with reduced operative duration and blood loss, increased rate of occipital numbness, and no change in the rate of occipital neuralgia. However, given the relatively low quality of evidence, prospective, controlled studies to evaluate this strategy are recommended. Level of evidence N /A.

Purpose To determine the impact of using sucralfate versus H2RAs for SUP on patient important outcomes. Materials and methods We searched CENTRAL, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through June 2016 for randomized controlled trials (RCTs) comparing sucralfate to H2RAs for SUP in adult critically ill patients. Results 21 RCTs enrolling 3121 patients met inclusion criteria. There was no significant difference between sucralfate compared to H2RAs in the risk of clinically important GI bleeding (risk ratio [RR] 1.19; 95% CI [confidence interval] 0.79, 1.80; P = 0.42; I 2 = 0%; low quality evidence). However, there was a statistically significant lower risk of ICU acquired pneumonia with sucralfate compared to H2RAs (RR 0.84; 95% CI 0.72, 0.98; P = 0.03; I 2 = 0%; moderate quality evidence). Sucralfate did not significantly affect the risk of death (RR 0.95; 95% CI 0.82, 1.10; P = 0.51; I 2 = 0%; high quality evidence), or duration of ICU stay in days (mean difference − 0.39; 95% CI [− 1.12, 0.34]; P = 0.29; I 2 = 0%; moderate quality evidence). Trial sequential analysis adjusted estimates were consistent with conventional estimates. Conclusion Moderate quality evidence suggests that sucralfate reduced ICU acquired pneumonia compared to H2RAs in adult critically ill patients, with no significant impact on GI bleeding or death.

The surgical risk factors and neuro-imaging characteristics associated with cerebellar mutism (CM) remain unclear and require further investigation. Therefore, we aimed to examine surgical and MRI findings associated with CM in children following posterior fossa tumor resection. Using our data registry, we retrospectively collected data from pediatric patients who acquired CM and were matched based on age and pathology type with individuals who did not acquire CM after posterior fossa surgery. The strength of association between surgical and MRI variables and CM were examined using odds ratios (ORs) and corresponding 95% confidence intervals (CIs). A total of 22 patients (11 with and 11 without CM) were included. Medulloblastoma was the most common pathology among CM patients (91%); the remaining 9% were diagnosed with a pilocytic astrocytoma. Tumor attachment to the floor of the fourth ventricle (OR 6; 95% CI 0.7-276), calcification/hemosiderin deposition (OR 7; 95% CI 0.9-315.5), and post-operative peri-ventricular ischemia on MRI (OR 5; 95% CI 0.5-236.5) were found to have the highest measures of association with CM. Our results may suggest that tumor attachment to the floor of the fourth ventricle, pathological calcification, and post-operative ischemia have a relatively higher prevalence in patients with CM. Collectively, our work calls for a larger multi-institutional cohort study of CM patients to encourage further investigation of the determinants and management of CM in order to potentially minimize its development and predict onset.

Background Intolerance to enteral nutrition is common in critically ill adults, and may result in significant morbidity including ileus, abdominal distension, vomiting and potential aspiration events. Prokinetic agents are prescribed to improve gastric emptying. However, the efficacy and safety of these agents in critically ill patients is not well-defined. Therefore, we conducted a systematic review and meta-analysis to determine the efficacy and safety of prokinetic agents in critically ill patients. Methods We searched MEDLINE, EMBASE, and Cochrane Library from inception up to January 2016. Eligible studies included randomized controlled trials (RCTs) of critically ill adults assigned to receive a prokinetic agent or placebo, and that reported relevant clinical outcomes. Two independent reviewers screened potentially eligible articles, selected eligible studies, and abstracted pertinent data. We calculated pooled relative risk (RR) for dichotomous outcomes and mean difference for continuous outcomes, with the corresponding 95 % confidence interval (CI). We assessed risk of bias using Cochrane risk of bias tool, and the quality of evidence using grading of recommendations assessment, development, and evaluation (GRADE) methodology. Results Thirteen RCTs (enrolling 1341 patients) met our inclusion criteria. Prokinetic agents significantly reduced feeding intolerance (RR 0.73, 95 % CI 0.55, 0.97; P = 0.03; moderate certainty), which translated to 17.3 % (95 % CI 5, 26.8 %) absolute reduction in feeding intolerance. Prokinetics also reduced the risk of developing high gastric residual volumes (RR 0.69; 95 % CI 0.52, 0.91; P = 0.009; moderate quality) and increased the success of post-pyloric feeding tube placement (RR 1.60, 95 % CI 1.17, 2.21; P = 0.004; moderate quality). There was no significant improvement in the risk of vomiting, diarrhea, intensive care unit (ICU) length of stay or mortality. Prokinetic agents also did not significantly increase the rate of diarrhea. Conclusion There is moderate-quality evidence that prokinetic agents reduce feeding intolerance in critically ill patients compared to placebo or no intervention. However, the impact on other clinical outcomes such as pneumonia, mortality, and ICU length of stay is unclear. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1441-z) contains supplementary material, which is available to authorized users.

Background A variety of subdural pathologies that may mimic hematomas are reported in the literature. We aimed to identify the atypical clinical and radiologic presentations of subdural masses that may mimic subdural hematomas. Methods A systematic review of MEDLINE and Embase was conducted independently by 2 reviewers to identify articles describing subdural hematoma mimickers. We also present a patient from our institution with a subdural pathology mimicking a subdural hematoma. We analyzed patient clinical presentations, underlying pathologies, radiologic findings, and clinical outcomes. Results We included 43 articles totaling 48 patients. The mean ± SD patient age was 55.7 ± 16.8 years. Of the 45 cases describing patient history, 13 patients (27%) had a history of trauma. The underlying pathologies of the 48 subdural collections were 10 metastasis (21%), 14 lymphoma (29%), 7 sarcoma (15%), 4 infectious (8%), 4 autoimmune (8%), and 9 miscellaneous (19%). Findings on computed tomography (CT) scan were 18 hyperdense (41%), 11 hypodense (25%), 9 isodense (20%), 3 isodense/hyperdense (7%), and 3 hypodense/isodense (7%). Thirty-four patients (71%) were treated surgically; among these patients, 65% had symptom resolution. Neither the pathology ( P = 0.337) nor the management strategy ( P = 0.671) was correlated with improved functional outcomes. Conclusions Identification of atypical history and radiologic features should prompt further diagnostic tests, including magnetic resonance imaging (MRI), to elucidate the proper diagnosis, given that certain pathologies may be managed nonsurgically. A subdural collection that is hyperdense on CT scan and hyperintense on T2-weighted MRI, along with a history of progressive headache with no trauma, may raise the suspicion of an atypical subdural pathology.

Purpose Stress ulcer prophylaxis (SUP) is commonly prescribed in the intensive care unit. However, data from systematic reviews and conventional meta-analyses are limited by imprecision and restricted to direct comparisons. We conducted a network meta-analysis of randomized clinical trials (RCTs) to examine the safety and efficacy of drugs available for SUP in critically ill patients. Methods We searched MEDLINE, EMBASE, and the Cochrane Library Central Register of Controlled Trials through April 2017 for randomized controlled trials that examined the efficacy and safety of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), and sucralfate for SUP in critically ill patients. No date or language restrictions were applied. Data on study characteristics, methods, outcomes, and risk of bias were abstracted by two reviewers. Results Of 96 potentially eligible studies, we included 57 trials enrolling 7293 patients. The results showed that PPIs are probably more effective for preventing clinically important gastrointestinal bleeding (CIB) than H2RAs [odds ratio (OR) 0.38; 95% confidence interval (95% CI) 0.20, 0.73], sucralfate (OR 0.30; 95% CI 0.13, 0.69), and placebo (OR 0.24; 95% CI 0.10, 0.60) (all moderate quality evidence). There were no convincing differences among H2RA, sucralfate, and placebo. PPIs probably increase the risk of developing pneumonia compared with H2RAs (OR 1.27; 95% CI 0.96, 1.68), sucralfate (OR 1.65; 95% CI 1.20, 2.27), and placebo (OR 1.52; 95% CI 0.95, 2.42) (all moderate quality). Mortality is probably similar across interventions (moderate quality). Estimates of baseline risks of bleeding varied significantly across studies, and only one study reported on Clostridium difficile infection. Definitions of pneumonia varied considerably. Most studies on sucralfate predate pneumonia prevention strategies. Conclusions Our results provide moderate quality evidence that PPIs are the most effective agents in preventing CIB, but they may increase the risk of pneumonia. The balance of benefits and harms leaves the routine use of SUP open to question. Electronic supplementary material The online version of this article (10.1007/s00134-017-5005-8) contains supplementary material, which is available to authorized users.

The meta-analysis by Elgendy et al. [(1)][1] on mechanical thrombectomy for acute ischemic stroke pools estimates from 9 randomized trials. According to the study’s selection criteria, only trials that randomized patients within 4.5 h of stroke onset were included. However, strict application of

IntroductionIncreased intracranial pressure (ICP) is a significant neurological issue that may lead to permanent neurological sequelae. When evaluating patients with traumatic brain injury, it is crucial to identify those with high ICP in order to expedite ICP lowering measures and maintain adequate cerebral perfusion. Several measures are used to recognise patients with increased ICP including CT scan, MRI, ICP monitor, and lumbar puncture (LP). However, these tests can be invasive, associated with radiation exposure, contraindicated, or not readily available. Ultrasonography measurement of the optic nerve sheath diameter (ONSD) is proposed as a non-invasive and quick measure to identify high ICP. The aim of this systematic review and meta-analysis will be to examine the accuracy of ONSD sonography for increased ICP diagnosis.Methods and analysesWe will include published and unpublished randomised controlled trials, observational studies, and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, Embase, Web of Science, WHO Clinical Trials, ClinicalTrials.gov, CINAHL, and the Cochrane Library databases. We will also implement strategies to search grey literature. Two reviewers will independently complete data abstraction and conduct quality assessment. Included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We will construct the hierarchical summary receiver operating characteristic curve for included studies and pool sensitivity and specificity using the bivariate model. We also plan to conduct prespecified subgroup analyses to explore heterogeneity. The overall quality of evidence will be rated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).Ethics and disseminationResearch ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on ONSD sonography diagnostic accuracy and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication.PROSPERO registration numberCRD42017055485.Clinical trial numberTrial registration number isNCT00783809.

Background: Current guidelines recommend early enteral nutrition in the critically ill. Nutritional deficiencies in this population may result in unfavorable outcomes. However, enteral nutrition may be complicated with feeding intolerance, aspiration, pneumonia, and interruption of feeding. Objectives: We updated our systematic review and meta-analysis that compared the effect of postpyloric and gastric feeding on risk of pneumonia, duration of mechanical ventilation (MV), Intensive Care Unit (ICU) length of stay (LOS), gastrointestinal (GI) bleeding, aspiration, vomiting, and mortality. Methods: We searched MEDLINE, EMBASE, and clinical registries for data through April 2017 without language or date of publication restrictions. We included randomized controlled trials (RCTS) comparing postpyloric feeding to gastric feeding. Two reviewers independently screened titles and abstracts for eligibility and extracted data in duplicate. Reviewers used the Cochrane Collaboration tool to assess the risk of bias, and the Grading of Recommendations, Assessment, Development, and Evaluation methodology to assess the quality of the evidence. We used trial sequential analysis (TSA) as a sensitivity analysis to adjust for sequential testing. Results: We included 21 RCTs (1573 patients). Postpyloric feeding reduced the risk of nosocomial pneumonia (relative risk [RR] 0.73; 95% confidence interval [CI] 0.57, 0.95; P = 0.02; I2 = 11%; moderate quality), ventilator-associated pneumonia (RR 0.74, 95% CI 0.57, 0.96; P = 0.02; I2 = 10%, moderate quality), and duration of MV (mean difference [MD] - 2.10 days, 95% CI −3.93, −0.28; P = 0.02; I2 = 67%, low quality), compared to gastric feeding. There was no difference in mortality (RR 1.07, 95% CI 0.90, 1.27; P = 0.44; I2 = 0%, moderate quality), ICU LOS (MD - 1.01 days, 95% CI −3.32, 1.3; P = 0.39; I2 = 84%, very low quality), aspiration (RR 0.81, 95% CI 0.4, 1.60, P = 0.54; I2 = 21%, very low quality), vomiting (RR 0.97, 95% CI 0.70, 1.36, P = 0.87; I2 = 33%, very low quality), and GI bleeding (RR 0.88, 95% CI 0.56, 1.38; P = 0.56; I2 = 0%, very low quality). Sensitivity analysis using TSA mirrored those of conventional analyses. Conclusions: Moderate quality evidence showed that postpyloric feeding may reduce the risk of pneumonia. Low-quality evidence yielded that duration of MV is shorter with pyloric compared to gastric feeding, with no significant impact on other outcomes. Although the results are promising further assessment in large clinical trials is warranted.

The relative efficacy and safety of proton pump inhibitors (PPIs) compared to histamine-2-receptor antagonists (H2RAs) should guide their use in reducing bleeding risk in the critically ill. We searched the Cochrane library, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through November 2015 without language or publication date restrictions. Only randomized controlled trials (RCTs) of PPIs vs H2RAs for stress ulcer prophylaxis in critically ill adults for clinically important bleeding, overt gastrointestinal (GI) bleeding, nosocomial pneumonia, mortality, ICU length of stay and Clostridium difficile infection were included. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the evidence for each outcome. In 19 trials enrolling 2117 patients, PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding (RR 0.39; 95 % CI 0.21, 0.71; P = 0.002; I 2 = 0 %, moderate confidence) and overt GI bleeding (RR 0.48; 95 % CI 0.34, 0.66; P