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Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90 th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: The COVID-19 pandemic has caused severe economic consequences by local governmental measures to contain the outbreak. We provide insight on the impact that health care restriction has made on neurosurgical activity in Latin Iberoamerica., Methods: We performed an internet-based survey among presidents and members of the societies of the Latin American Federation of Neurosurgical Societies (FLANC). We blindly analyzed information regarding local conditions and their impact on neurosurgical praxis using SPSS software., Results: Information came from 21 countries. Sixteen society presidents reported having suspended regular activities and deferring local scheduled congresses, 14 reported mandatory isolation by government, and 4 instituted a telemedicine project. Four-hundred eighty-six colleagues, mean age 49 years, reported a mean 79% reduction in their neurosurgical praxis. Seventy-six percent of neurosurgeons have savings to self-support for 3-6 months if restrictions are long lasting., Conclusions: Stopping activities among societies of the FLANC, together with a drop of 79% of neurosurgical praxis, adds to deficits in provider's protection equipment and increasing demand for attention in the health care systems, representing a huge financial risk to their sustainability. Neurosurgeons should be involved in local policies to protect health and economy. Telemedicine represents an excellent solution, avoiding another pandemic of severe diseases across all-specialties as nonessential care can turn essential if left untreated. Financial support and ethics code review is needed to battle this new disease, designated the occupational disease of the decade, that continues to scrag the health care system. Times of crisis are times of great opportunities for humanity to evolve., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Patients undergoing trigger-site deactivation surgery for headaches report a high prevalence (approximately 37 percent) of prior head or neck injury. Traditional medical treatment often fails to treat these posttraumatic patients. It is unclear whether surgery mirrors these poor outcomes. This study aims to describe the characteristics of posttraumatic headache surgery patients and compare their postoperative results to those of patients without a history of head or neck injury., Methods: One hundred forty-two patients undergoing trigger-site deactivation surgery were prospectively enrolled. Patients were requested to complete a preoperative questionnaire on headache history, including the Migraine Headache Index and information on prior head or neck injury. Follow-up surveys were requested at approximately 12 months postoperatively., Results: Seventy patients (49 percent) reported a history of head or neck injury, and 41 (29 percent) classified the injury as the precipitating event leading to their headache onset. Patients with a precipitating event were significantly less likely to report a family history of migraine. There was no significant difference in mean preoperative Migraine Headache Index between cohorts. At 12 months postoperatively, there was no significant difference in Migraine Headache Index reduction between groups. The proportion of patients who experienced at least a 50 and 80 percent improvement in Migraine Headache Index per group, respectively, was 83 and 67 percent (atraumatic), 76 and 68 percent (posttraumatic), and 71 and 63 percent (precipitating event)., Conclusions: This study suggests that surgical outcomes in posttraumatic headache patients are comparable to those without injury. Trigger-site deactivation surgery candidates with a history of injury can therefore expect similar outcomes as reported for patients overall., Clinical Question/level of Evidence: Risk, II.

Background: Glioblastoma (GBM) is the most frequent intraaxial malignant brain tumour, in which recurrence management is a frequent and demanding issue. Recently, reintervention has emerged as a useful tool for treatment. However, some new evidence has shown that most of the articles published could have overestimated its effects. We aimed to analyse the effect on survival of reintervention considering it as a time-dependent variable and to compare it with classic statistical analysis., Methods: We performed a retrospective study with GBM patients between 2007 and 2017. We compared the overall survival (OS) between reintervention and non-reintervention groups with time-dependent statistical methods (Simon-Makuch and landmarking methods and time-dependent multivariable Cox analysis) and compared them with those obtained with non-dependent time variable analysis., Results: A total of 183 patients were included in the analysis and 44 of them were reoperated. The standard analysis with Kaplan-Meier and multivariable Cox regression of the cohort showed an OS of 22.2 months (95% CI 12.56-16.06) in the reintervention group and 11.8 months (95% CI 9.87-13.67) in the non-reintervention group (p < .001); and an HR 0.649 (95% CI 0.434-0.97 p = .035) for reintervention, demonstrating an increase in OS. However, time-dependent analysis with the Simon-Makuch test and the landmarking method showed that the relationship was not consistent, as this increase in OS was not significant. Moreover, time-dependent multivariable Cox analysis did not show that reintervention improved OS in our cohort (HR 0.997 95% CI 0.976-1.018 p = 0.75)., Conclusions: There has been a temporal bias in the literature that has led to an overestimation of the positive effect of reintervention in recurrent GBM. However, reintervention could still be useful in some selected patients, who should be individualized according to prognostic factors related to the patient, biology of the tumour, and characteristics of surgical procedure.

Background: Although nontraumatic diseases affect fewer people than traumatic neurosurgical diseases, they require expertise more often. The authors sought to understand the barriers to nontraumatic neurosurgical diseases (NTNSDs) in a country with limited access to neurosurgical care., Methods: This cross-sectional study with retrospective data collection was carried out in 2 Cameroonian reference hospitals for a year. Multiple imputations were used to generate data for the missing variables-death and discharge with sequelae. Bivariate relationships were evaluated using the chi-square and Mann-Whitney U tests. Odds ratios were equally calculated, and the results were considered significant for a P value <0.05., Results: NTNSDs represented 44.1% of neurosurgical activity. Our study included 177 patients with a mean age of 43.7 ± 21.2 years. More than half (53.1%) were female, 78% lived in a different region from that of the neurosurgical center, 18.1% had health insurance, 39.5% were referrals, and the mean symptom-to-admission delay was 409.0 ± 1301.7 days. Most (87%) of the patients had undergone at least 1 of the diagnostic examinations prescribed to them. Men (P = 0.029) and rural dwellers (P = 0.017) had shorter symptom-to-admission delays than women and urban dwellers, respectively. The mean length of stay was 18.2 ± 13.4, and 80.8% of patients were treated surgically. Thirty-one (17.5%) patients died in the hospital: 9 were treated surgically, and 22 were treated conservatively or expectantly., Conclusions: Patients with NTNSD present at the definitive care facilities late. This delay is attributable to financial and geographic barriers., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Metastatic atypical teratoid/rhabdoid tumors (AT/RTs) are aggressive central nervous system tumors that present during infancy and are associated with dismal outcomes. Patients receive multimodal treatment including surgical resection, systemic chemotherapy, and one or more of intrathecal chemotherapy (IT), marrow-ablative chemotherapy with autologous hematopoietic cell rescue (AuHCR) and radiation therapy (XRT). While data regarding treatment modalities for AT/RT patients exist, no comprehensive data have been published regarding the metastatic patients., Methods: We performed a meta-analysis of 1578 articles published through September 2018, including 44 studies with a total of 123 subjects. In addition, seven patients were included through chart review of patients treated at Nationwide Children's Hospital., Results: Analysis of 130 patients revealed a 3-year overall survival (OS) of 25%. Age at diagnosis had a significant effect on survival (P = 0.0355); 3-year OS for infants less than 18 months was 21%, 18 to 36 months was 26%, and greater than 36 months was 36%. Location of the primary tumor, metastatic stage, and extent of surgical resection did not have a significant impact on OS. On univariate analysis, XRT (P < 0.0001), IT (P = 0.01), and AuHCR (P < 0.0001) were found to significantly improve survival. The most substantial effect was noted in patients who received AuHCR (3-year OS of 60% vs 9% in those who did not). On multivariable analysis, XRT (P = 0.0006), IT (P = 0.0124), and AuHCR (P < 0.0001) were independently associated with reduced risk of death., Conclusions: Although more research is warranted to make generalizable conclusions, these results suggest that treatment regimens for patients with metastatic AT/RTs should include AuHCR, XRT, and IT., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Importance: Occult spinal dysraphism (OSD) is the most common congenital spinal anomaly. Cutaneous anomalies such as skin dimples or deviated gluteal folds are well known as stigmata of OSD and are indicators for further evaluation; however, the association between cutaneous anomalies and OSD has not been systemically evaluated., Objective: To evaluate the incidence of OSD and the proportion of OSD cases managed with a neurosurgical intervention among neonates or infants with various cutaneous stigmata., Data Sources: PubMed and Embase databases were searched for studies published up to July 25, 2018, that evaluated the proportion of OSD cases in neonates or infants with cutaneous stigmata. Search terms included ultrasound, dysraphism, dimple, and infant or neonate. The search was limited to English-language publications., Study Selection: Two reviewers selected the studies evaluating the incidence of OSD among neonates or infants with cutaneous stigmata., Data Extraction and Synthesis: The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for data extraction were followed. Pooled proportions of OSD cases and OSD cases that were managed with a neurosurgical intervention were obtained using the generalized linear mixed model and maximum likelihood method., Main Outcome and Measures: The pooled incidence of OSD and OSD cases managed with neurological surgery among patients with cutaneous stigmata was the primary outcome. This outcome was also evaluated in each subgroup, and heterogeneity was explored using subgroup analysis., Results: A total of 15 studies, involving 6558 neonate or infant patients with various cutaneous stigmata, were included. The pooled proportion of OSD cases among the patients with cutaneous stigmata was 2.8% (95% CI, 2.1%-3.8%; I2 = 51.6%), and the proportion managed with neurological surgery was 0.6% (95% CI, 0.3%-1.3%; I2 = 66.4%). Cases with combined stigmata showed a significantly higher association with OSD than those with a single stigma (10.5% [95% CI, 6.9%-15.8%] vs 2.3% [%, 95% CI, 1.5%-3.5%]; P < .001). The pooled proportion of OSD cases among patients with an atypical dimple was significantly higher than among those with simple dimple (8.8% [95% CI, 4.5%-16.6%] vs 0.6% [95% CI of 1.4%-2.1%]; P = .001)., Conclusions and Relevance: The proportion of OSD in healthy, asymptomatic patients with midline cutaneous stigmata was low, and the proportion of patients who underwent a neurosurgical intervention was even lower. However, a careful evaluation as well as potential spinal magnetic resonance imaging is recommended for neonates or infants with combined stigmata or an atypical dimple for possible high-risk lesions.

Background: Diabetes mellitus (DM) is associated with poor postoperative outcomes and increased morbidity after surgeries. Some previous studies have addressed the close association between DM and those leading to reoperations, whereas others have rejected this theory. This study aimed to evaluate the long-term effect of DM on lumbar spinal surgery using data from a nationwide sample cohort., Methods: A population-based cohort comprised one million people, which is a 2.1% representative sample of the Korean population. The present study included adult patients with lumbar degenerative diseases (e.g., lumbar spinal stenosis and spondylolisthesis), who underwent their first lumbar surgery in 2006. The cumulative incidence function for reoperation was calculated and multivariate analysis was performed to define correlation between reoperation and independent factors., Results: A total of 2020 patients were enrolled and followed up for 10 years. Nondiabetic patients, patients with DM without complication (DwoC), and patients with DM with complication (DwC) accounted for 79.5%, 9.36%, and 11.14% of all patients, respectively. Reoperation incidence stratified by DM was 12.7% for nondiabetic patients, 22.2% for patients with DwoC, and 20.0% for patients with DwC in 10 years of follow-up. During the same period, death, a competing event of reoperation, occurred in 7.8% of nondiabetic patients, in 13.2% of patients with DwoC, and in 20.9% of patients with DwC., Conclusions: DM increased 1.65 times the overall cumulative incidences of reoperation after lumbar spinal surgeries for 10 years of follow-up. The reoperation incidence for DwC may be lower than that for DwoC because of a high incidence of death as a competing event of reoperation., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Trauma patients with isolated subarachnoid hemorrhage (iSAH) presenting to nontrauma centers are typically transferred to an institution with neurosurgical availability. However, recent studies suggest that iSAH is a benign clinical entity with an excellent prognosis. This investigation aims to evaluate the neurosurgical outcomes of traumatic iSAH with Glasgow Coma Scale (GCS) of 13 to 15 who were transferred to a higher level of care., Methods: The American College of Surgeon Trauma Quality Improvement Program was retrospectively analyzed from 2010 to 2015 for transferred patients 16 years and older with blunt trauma, iSAH, and GCS of 13 or greater. Those with any other body region Abbreviated Injury Scale of 3 or greater, positive or unknown alcohol/drug status, and requiring mechanical ventilation were excluded. The primary outcome was need for neurosurgical intervention (i.e., intracranial monitor or craniotomy/craniectomy)., Results: A total of 11,380 patients with blunt trauma, iSAH, and GCS of 13 to 15 were transferred to an American College of Surgeon level I/II from 2010 to 2015. These patients were 65 years and older (median, 72 [interquartile range (IQR), 59-81]) and white (83%) and had one or more comorbidities (72%). Eighteen percent reported a bleeding diathesis/chronic anticoagulation on admission. Most patients had fallen (80%), had a GCS of 15 (84%), and were mildly injured (median Injury Severity Score, 9 [IQR, 5-14]). Only 1.7% required neurosurgical intervention with 55% of patients being admitted to the intensive care unit for a median of 2 days (IQR, 1-3 days). Furthermore, 2.2% of the patients died. The median hospital length of stay was only 3 days (IQR, 2-5 days), and the most common discharge location was home with self-care (62%). Patient factors favoring neurosurgical intervention included high Injury Severity Score, low GCS, and chronic anticoagulation., Conclusion: Trauma patients transferred for iSAH with GCS of 13 to 15 are at very low risk for requiring neurosurgical intervention., Level of Evidence: Therapeutic/care management, Level IV.

Purpose: The aim of this study was to determine and compare the waiting times for surgical assessment, neuropsychological testing and epilepsy surgery between people with epilepsy who live in cities with available neurologists vs not., Methods: We reviewed all cases referred for epilepsy surgery between 2007 and 2017 at the Saskatchewan Epilepsy Program Royal University Hospital (SEP) (n = 98; Saskatchewan, Canada). Mann-Whitney U test was used to compare wait times from first diagnosis of epilepsy to epilepsy surgery between patients who live in cities with neurologists (mainly urban areas) vs cities without neurologists (mainly rural areas)., Results: The mean age of patients who enrolled in SEP was 37.8 ± 12.8 years. The median wait time from date of epilepsy diagnosis to referral was 9.5 years in Saskatoon and Regina (cities with available neurologists) and 14 years in other areas of Saskatchewan (small cities and rural areas with no available neurologists) (p = 0.03). The median wait time from date of epilepsy diagnosis to first consult with the epileptologist was 10 years in Saskatoon and Regina and 15.5 years in other areas of Saskatchewan (p = 0.03). The median wait time from date of first diagnosis to epilepsy surgery was 13.2 years in Saskatoon and Regina and 18.2 years in other areas of Saskatchewan (p = 0.05)., Conclusion: A notable difference was observed in surgical wait times between patients who live in cities with available neurologists compared with people living in rural areas and cities with no neurologists. This suggests that delayed surgical treatment for epilepsy is related with the availability of neurologists., Competing Interests: Declaration of Competing Interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020 British Epilepsy Association. All rights reserved.)

Background: This study assesses the influence of race on patient outcomes in a brain tumor surgery population., Methods: Coarsened exact matching was used to retrospectively analyze 1700 supratentorial brain tumor procedures over a 6-year period (June 7, 2013 to April 29, 2019) at a single, multihospital academic medical center. Outcome measures included readmission, mortality, emergency room visits, and reoperation., Results: McNemar test (mid-P) showed no significant difference in 90-day mortality between the 2 races (P = 0.3018). However, there was a significant difference in 90-day readmissions between the 2 races (P = 0.0237). There was no significant difference in 90-day emergency room visits (P = 0.0579), 90-day return to surgery after index admission (P = 0.6015), or return to surgery within 90 days (P = 0.6776) between the 2 races. There was also no significant difference in return to surgery for the duration of the follow-up period (P = 0.8728)., Conclusions: This study suggests that race alone does not result in disparate outcomes; however, there was an associated difference in 90-day postsurgical readmissions. Despite coarsened exact matching, persistent differences in median household income may play a role in the disparate outcome noted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: Evidence is limited regarding clinical factors associated with ambulation status over the lifespan of individuals with myelomeningocele. We used longitudinal data from the National Spina Bifida Patient Registry to model population-level variation in ambulation over time and hypothesized that effects of clinical factors associated with ambulation would vary by age and motor level., Design: A population-averaged generalized estimating equation was used to estimate the probability of independent ambulation. Model predictors included time (age), race, ethnicity, sex, insurance, and interactions between time, motor level, and the number of orthopedic, noncerebral shunt neurosurgeries, and cerebral shunt neurosurgeries., Results: The study cohort included 5371 participants with myelomeningocele. A change from sacral to low-lumbar motor level initially reduced the odds of independent ambulation (OR = 0.24, 95% CI = 0.15-0.38) but became insignificant with increasing age. Surgery count was associated with decreased odds of independent ambulation (orthopedic: OR = 0.65, 95% CI = 0.50-0.85; noncerebral shunt neurosurgery: OR = 0.65, 95% CI = 0.51-0.84; cerebral shunt: OR = 0.90, 95% CI = 0.83-0.98), with increasing effects seen at lower motor levels., Conclusions: Our findings suggest that effects of several commonly accepted predictors of ambulation status vary with time. As the myelomeningocele population ages, it becomes increasingly important that study design account for this time-varying nature of clinical reality., To Claim Cme Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe general trends in ambulation status by age in the myelomeningocele population; (2) Recognize the nuances of cause and effect underlying the relationship between surgical intervention and ambulation status; (3) Explain why variation of clinical effect over time within myelomeningocele population matters., Level: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Our research aims to assess the change in the grade of responsiveness using the Hunt and Hess score as well as the modified ranking scale in patients suffering from anterior communicating artery rupture. We retrospectively analyzed data from 11-patients who suffered from an anterior communicating artery aneurysm rupture that caused a subarachnoid hemorrhage. Severity was assessed using the Hunt and Hess scale grade and modified ranking scale. Anterior communicating artery rupture caused a subarachnoid hemorrhage in 40.81% of all aneurysm ruptures that took place at the Circle of Willis. Unfortunately, 4-patients deceased (3.4%) at a median age of 52-years (range 34-75-years), three of which deceased after coiling and one after clipping. In 71-patients (61.2%) endovascular coiling was performed - 33-males and 38-females - and in the remaining 45-cases, (38.8%) clipping was indicated - 24-males and 21-females. Overall, the pre-interventional median Hunt and Hess scale was 2, which remained after the intervention. When relating the outcome score to the intervention performed, we found that the Hunt and Hess scale score was 3 before coiling and 2 before clipping, whereas afterward, there was a slight increase to 2 and 2, respectively. The modified ranking scale was 2 after clipping, respectively, coiling ( P = 0.218). No significant differences were observed between the different groups. Our results show that clipping is as effective as coiling in terms of the Hunt and Hess scale and the rate of mortality in the short-term., Competing Interests: The authors declare that they don't have any conflict of interest related to this study., (© 2020 Bäcker et al. Published by IMR press.)

Reports on pediatric low-grade glioma (LGG) of the caudal brainstem are retrospective with heterogeneous cohorts, variable treatments and inconsistent outcome data. We analyzed their natural history and asked whether brainstem location proved unfavorable for survival within the framework of the comprehensive SIOP-LGG 2004 management strategy. Within the prospectively registered, population-based German SIOP-LGG 2004 cohort 116 patients (age 0.2-16.5 years, 10% Neurofibromatosis NF1) were diagnosed with LGG of the pons (27%) and medulla oblongata (73%). After biopsy (23%), variable resection (63%) or radiologic diagnosis only (14%), 59 patients received no adjuvant treatment. Radiologic progression or severe neurologic symptoms prompted chemo- (n = 39) or radiotherapy (n = 18). After further progression (28/57), salvage treatments included multiple treatment lines for 12/28 patients. Five-years event-free survival dropped to 0.40, while 5-years overall survival was 0.95 (median observation time 6.8 years). Higher extent of resection yielded lower progression rate (p = 0.001), but at a cost of 21/100 patients suffering from new postsurgical complications including respiratory insufficiency. Central review confirmed pilocytic astrocytoma (56%), diffuse astrocytoma (8%) or glioneuronal histology (16%) (others 4%, no histology 17%). Malignant evolution was documented in five patients associated with Histone3 mutation in 2/5. Our treatment algorithm conveyed high overall survival for pediatric brainstem LGG. Extensive neurosurgical resection did increase additional postoperative neurologic deficits but not overall survival in this often-chronic disease. More than half of all patients can be safely followed by observation, while multimodal adjuvant treatment can control progressive tumors. Molecular assessment should confirm low-grade diagnosis and may detect patterns prognostic for malignant evolution., (© 2019 The Authors. International Journal of Cancer published by John Wiley & Sons Ltd on behalf of UICC.)

Background: Chronic subdural hemorrhage (CSDH) is a common neurosurgical pathology. While acute deterioration is managed surgically, the optimal management of patients with neurologically stable CSDH remains uncertain. Despite an increasing interest in the use of corticosteroids, it is unclear whether this reduces the rate of subsequent crossover to surgery. In this study we evaluate rate of crossover to surgery in such patients managed in our Neurosurgical unit., Methods: A retrospective database search over a 2-year period was performed. A multi-database literature review was also conducted to identify relevant articles reporting rate of subsequent surgery in CSDH patients managed with corticosteroids., Results: A total of 532 CSDH patients were identified. Subsequently, a total of 364 patients who were managed conservatively were included for further analysis. The majority (315 patients; 59.1%) were managed conservatively. Forty-nine patients (9.2%) received steroids as first-line treatment. There was considerable variation in steroid dosing regimens, with the commonest involving 4 mg dexamethasone three times daily for 5 days. Four patients in the steroid group required subsequent surgery (8.2%), compared with 22 conservatively managed patients (7.0%). Statistical analysis revealed no significant difference in the rate of surgery (chi-square 0.089, difference 1, P = 0.77)., Conclusions: Current evidence implicates a potentially beneficial role of dexamethasone in the management of CSDH. However, it remains unclear whether the rate of crossover to surgery is reduced in patients treated with corticosteroids compared with those managed conservatively. A longer duration of study with detailed analysis of individual cases and appropriately randomized cohorts are necessary to draw more reliable conclusions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Estimates of the rate and risk-factors for difficult airway rarely include a denominator for the number of anaesthetics. Approaches such as self-reporting and crowd-sourcing of airway incidents may help identify specific lessons from clinical episodes, but the lack of denominator data, biased reporting and under-reporting does not allow a comprehensive population-based assessment. We used an established state-wide dataset to determine the incidence of failed and difficult intubations between 2015 and 2017 in the state of Victoria in Australia, along with associated patient and surgical risk-factors. A total of 861,533 general anaesthesia episodes were analysed. Of these, 4092 patients with difficult or failed intubation were identified; incidence rates of 0.52% (2015-2016) and 0.43% (2016-2017), respectively. Difficult/failed intubations were most common in patients aged 45-75 and decreased for older age groups, with risk being lower for patients aged >85 than patients aged 35-44. The risk for failed/difficult intubation increased significantly for: patients undergoing emergency surgery (OR 1.80); obese patients (OR 2.48); increased ASA physical status; and increased Charlson Comorbidity Index. Across all age groups, procedures on the nervous system (OR 1.92) and endocrine system (OR 2.03) had the highest risk of failed/difficult intubation. The relative reduced risk for failed/difficult intubations in the elderly population is a novel finding that contrasts with previous research and may suggest a 'compression of morbidity' effect as a moderator. Administrative databases have the potential to improve understanding of peri-operative risk of rare events at a population level., (© 2020 Association of Anaesthetists.)

Background: Between 2010 and 2014, microscopic transsphenoidal surgery (mTSS) was performed more frequently than endoscopic TSS (eTSS) in the USA. However, few epidemiological studies on pituitary surgery are currently available., Methods: We performed a retrospective study on patients who had undergone pituitary surgery between July 2010 and March 2016. To this end, a nationwide inpatient database in Japan was used. Patients' characteristics, diagnoses, types of surgery, complications, and discharge status were examined., Results: A total of 16,253 inpatients who received pituitary surgery were identified. Patients were diagnosed with diseases for insurance claims described below: pituitary adenoma, hyperprolactinemia, other pituitary disorders (e.g., Rathke's cleft cyst), hyperpituitarism, craniopharyngioma, acromegaly, Cushing's disease, and pituitary cancer. Among them, pituitary adenomas, primarily the non-functioning ones, were the most frequent (66.9%). A total of 14,285 (88%) patients underwent TSS, while 1968 (12%) patients were treated using transcranial surgery. The number of patients undergoing TSS increased each year. The number of eTSS operations was 8140 (77%) and that of mTSS operations was 2419 (23%). Of note, eTSS increased each year. We found that high-volume hospitals more frequently selected eTSS. Compared with mTSS, eTSS was associated with a reduction of hyponatremia incidence (odds ratio, 0.69; p = 0.019). Additionally, it was not associated with other major complications., Conclusion: The present study showed that both TSS and eTSS increased on a yearly basis. We believe that the present study will be the basis of future epidemiological investigations of pituitary surgery.

Object: The COVID-19 pandemic has disrupted all aspects of society globally. As healthcare resources had to be preserved for infected patients, and the risk of in-hospital procedures escalated for uninfected patients and staff, neurosurgeons around the world have had to postpone non-emergent procedures. Under these unprecedented conditions, the decision to defer cases became increasingly difficult as COVID-19 cases skyrocketed., Methods: Data was collected by self-reporting surveys during two discrete periods: the principal survey accrued responses during 2 weeks at the peak of the global pandemic, and the supplemental survey accrued responses after that to detect changes in opinions and circumstances. Nine hypothetical surgical scenarios were used to query neurosurgeons' opinion on the risk of postponement and the urgency to re-schedule the procedures. An acuity index was generated for each scenario, and this was used to rank the nine cases., Results: There were 494 respondents to the principal survey from 60 countries. 258 (52.5%) reported that all elective cases and clinics have been shut down by their main hospital. A total of 226 respondents (46.1%) reported that their operative volume had dropped more than 50%. For the countries most affected by COVID-19, this proportion was 54.7%. There was a high degree of agreement among our respondents that fast-evolving neuro-oncological cases are non-emergent cases that nonetheless have the highest risk in postponement, and selected vascular cases may have high acuity as well., Conclusion: We report on the impact of COVID-19 on neurosurgeons around the world. From their ranking of the nine case scenarios, we deduced a strategic scheme that can serve as a guideline to triage non-emergent neurosurgical procedures during the pandemic. With it, hopefully, neurosurgeons can continue to serve their patients without endangering them either neurologically or risking their exposure to the deadly virus.

Background: Despite documented efficacy of surgical treatment in carefully selected patients, surgery is delayed and/or underutilized in both adult and children with focal onset epilepsy. The reasons for surgical delay are often assumed or theorized, and studies have predominantly targeted the adult population. To focus on a more targeted pediatric population and to determine identifiable reasons for intervention, this study aimed to investigate time to epilepsy surgery among pediatric patients with medically intractable epilepsy associated with focal cortical dysplasia and to identify sociodemographic and clinical associations in time to epilepsy surgery., Methods: We reviewed 96 consecutive pediatric patients who underwent surgery for medically intractable epilepsy with a diagnosis of focal cortical dysplasia. Descriptive statistics, univariate and multivariate analyses were conducted to study the association of sociodemographic variables of patients with focal cortical dysplasia and time to epilepsy surgery and postoperative seizure control., Results: We identified that non-white patients on average had a longer duration of epilepsy before surgery and traveled shorter distances for care. Non-white patients were more likely to have government-funded insurance. Patients who traveled the shortest distance to the surgical center underwent epilepsy surgery at an older age., Conclusions: Sociodemographic factors of travel distance, insurance, and race influenced time to epilepsy surgery for children with focal cortical dysplasia. Further research is warranted to target barriers in access to subspecialty care and develop ways to identify earlier the patients who may benefit from evaluation and deployment of surgical intervention., (Copyright © 2019. Published by Elsevier Inc.)

Objective: Hydrocephalus is a common, chronic illness that generally requires lifelong, longitudinal, neurosurgical care. Except at select research centers, surgical outcomes in the United States have not been well documented. Comparative outcomes across the spectrum of age have not been studied., Methods: Data were derived for the year 2015 from the Nationwide Readmissions Database, a product of the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. In this data set patients are assigned state-specific codes that link repeated discharges through the calendar year. Discharges with diagnostic codes for hydrocephalus were extracted, and for each patient the first discharge defined the index admission. The study event was readmission. Observations were censored at the end of the year. In a similar fashion the first definitive surgical procedure for hydrocephalus was defined as the index operation, and the study event was reoperation for hydrocephalus or complications. Survival without readmission and survival without reoperation were analyzed using life tables and Kaplan-Meier plots., Results: Readmission rates at 30 days ranged between 15.6% and 16.8% by age group without significant differences. After the index admission the first readmission alone generated estimated hospital charges of $2.25 billion nationwide. Reoperation rates at 30 days were 34.9% for infants, 39.2% for children, 47.4% for adults, and 32.4% for elders. These differences were highly significant. More than 3 times as many index operations were captured for adults and elders as for infants and children. Estimated 1-year reoperation rates were 74.2% for shunt insertion, 63.9% for shunt revision, but only 34.5% for endoscopic third ventriculostomy. Univariate associations with survival without readmission and survival without reoperation are presented., Conclusions: In the United States hydrocephalus is predominantly a disease of adults. Surgical outcomes in this population-based study were substantially worse than outcomes reported from research centers. High reoperation rates after CSF shunt surgery accounted for this discrepancy.

Background: The COVID-19 pandemic has created an unprecedented challenge for medical professionals throughout the world to tackle the rapidly changing scenario. The objective of this survey was to analyze the change in neurosurgical practice in India following the COVID-19 outbreak and assess its impact on practising neurosurgeons., Materials and Methods: Between May 7 th and 23 rd , 2020, a validated questionnaire was circulated amongst practising neurosurgeons across the country by social media and e-mails, regarding changes in the patterns of patients seen, adaptations made in their practice, effect on surgeries performed, financial burden, and impact on their personal lives. The responses were kept anonymous and were analyzed for correlations between the changes observed and independent factors such as hospital affiliations, teaching professions, and neurosurgical experience., Results: Our survey showed a drastic fall in the number of neurosurgical patients seen in the outpatient department (OPD) as well as the number of surgeries performed. A drop of 76.25% was seen in OPD patients (P = 0.000) and that of 70.59% in surgeries performed (P = 0.000). There was no uniformity among the neurosurgeons in the number of COVID-19 tests being done before elective/emergency surgery and in the use of protective gear while examining patients. Private practitioners were more affected financially as compared to those in the government sector. The pandemic has affected the research work of 53.23% of all respondents, with those in the teaching profession (70.96%) more affected than those in the non-teaching profession (24.67%)., Conclusions: Evidence-based policies, screening COVID-19 tests with better sensitivity, and better-quality personal protective equipment kits in adequate numbers are required to protect our medical professionals from COVID-19. Mental health issues among neurosurgeons may also be an issue, this being a high risk speciality and should be closely watched for., Competing Interests: None

Background: The surgical management of penetrating spinal injury (PSI) has been widely debated in the literature, and the benefit of decompressive surgery for neurological function remains controversial. No national guidelines exist for the PSI population, and surgical practice patterns are unknown. We studied regional and institutional trends in the surgical management of PSI in the United States from 1988 to 2011., Methods: The National Inpatient Sample database was accessed to identify a 20% stratified sample of PSI admissions to US hospitals from 1988 to 2011. PSI patients were divided into surgical (SXPSI) and nonsurgical (NSXPSI) groups, and these groups were analyzed across several regional, institutional, and patient-related variables., Results: A total of 6632 PSI admissions were identified between 1988 and 2011. Decreased age (P = 0.002) and male gender (P = 0.015) were significantly more common in SXPSI than NSXPSI. Surgical rates were higher in teaching hospitals (P < 0.001), large hospitals (P = 0.012), and non-Northeast region hospitals (P < 0.020). Surgical management was associated with decreased mortality, increased length of stay, and increased total hospital charges (P < 0.001)., Conclusions: Decompressive surgery rates for PSI differ significantly across regions and institutions in the United States. Institutional bias, patient preferences, and regional practice patterns all influence decision-making in PSI. A lack of large outcome studies in PSI and the absence of national guidelines contribute to variation in practice patterns. Our study indicates the need for future studies to better describe outcomes in patients with PSI., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Guidelines for imaging anticoagulated patients following a traumatic injury are unclear. Interval CT head (CTH) is often routinely performed after initial negative CTH to assess for delayed intracranial hemorrhage (ICH-d). The rate of ICH-d for patients taking novel oral anticoagulants (NOACs) is unknown. We hypothesized that the incidence of ICH-d in patients on NOACs would be similar, if not lower to that of warfarin, and routine repeat CTH after initial negative would not change management, and thus, may not be indicated., Materials and Methods: Anticoagulated patients presenting with blunt trauma to a level I trauma center between 2016 and 2018 were evaluated. Exclusion criteria included: positive initial CTH and those taking nonoral anticoagulation or antiplatelet agents alone (without warfarin or NOAC). Outcomes included: ICH-d, discharge GCS, administration of reversal agents, neurosurgical intervention, readmission, and death. Multivariable regression was performed to evaluate patient factors associated with the development of ICH-d., Results: A total of 332 patients met the inclusion criteria. Patients were divided into a warfarin group (n = 191) and NOAC group (n = 141). The incidence of ICH-d in the warfarin group was 2.6% (5/191) and 2.1% (3/141) in the NOAC group (P = 0.77). There were no reversal agents administered, neurosurgical interventions, readmissions, or deaths in the NOAC group., Conclusions: Little is known about the impact of NOACs in the setting of trauma, especially regarding risks of ICH-d following traumatic injury. In the NOAC group, ICH-d occurred only 2.1% of the time. In addition, there were no reversal agents given, neurosurgical interventions, or deaths. These data, taken together, suggest the limited utility of repeat imaging in this patient population., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations) was the first randomized control trial to investigate unruptured cerebral arteriovenous malformation (cAVM) treatments and concluded that medical management was superior to interventional therapy for the treatment of unruptured cAVMs. This conclusion generated considerable controversy and was followed by rebuttals and meta-analyses of the ARUBA methodology and results. We sought to determine whether the ARUBA results altered treatment trends of cAVMs within the United States., Methods: Using the National Inpatient Sample, the largest all-payer inpatient care database within the United States, we isolated patients who were admitted on an elective basis for cAVM treatment and determined the treatment modality undergone by these patients. The cohort was dichotomized separately at 2 ARUBA time points: the European Stroke Conference presentation in May 2013, and The Lancet publication in February 2014., Results: We found that the overall treatment rate of unruptured cAVMs decreased after both time points. However, the rate of surgical excision alone, relative to other modalities, was significantly increased, and endovascular intervention demonstrated a nonsignificant decrease., Conclusions: Our findings suggest that the ARUBA trial has influenced unruptured cAVM treatment patterns within the United States. Although the overall treatment rate has decreased, unruptured cAVMs, when treated post-ARUBA, are most commonly approached with surgical excision alone., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Guidelines for management of intracranial hemorrhage do not account for bleed location. We hypothesize that parafalcine subdural hematoma (SDH), as compared to convexity SDH, is a distinct clinical entity and these patients do not benefit from critical care monitoring or repeat imaging., Methods: We identified patients presenting to a single level I trauma center with isolated head injuries from February 2016 to August 2017. We identified 88 patients with isolated blunt traumatic parafalcine SDH and 228 with convexity SDH., Results: Demographics, comorbidities, and use of antiplatelet and anticoagulant agents were similar between the groups. As compared to patients with convexity SDH, patients with parafalcine SDH had a significantly lower incidence of radiographic progression, and had no cases of neurologic deterioration, neurosurgical intervention, or mortality (all P < 0.005). Compared to patients admitted to the intensive care unit, patients with parafalcine SDH admitted to the floor had a shorter length of stay (2.0 ± 1.6 versus 3.8 ± 2.9 d, P < 0.005) with no difference in outcomes., Conclusions: Patients presenting with a parafalcine SDH are a distinct and relatively benign clinical entity as compared to convexity SDH and do not benefit from repeat imaging or intensive care unit admission., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: "1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated 'risk models' to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies." The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).

Background: Endoscopic carpal tunnel release (ECTR) and open carpal tunnel release (OCTR) both have advantages and disadvantages for the treatment of carpal tunnel syndrome (CTS). We compared the effectiveness and safety of ECTR and OCTR based on evidence from a high-level randomized controlled trial., Methods: We comprehensively searched PubMed, EMBASE, Cochrane Library, Web of Science, and Medline to identify relevant articles published until August 2019. Data regarding operative time, grip strength, Boston Carpal Tunnel Questionnaire scores, digital sensation, patient satisfaction, key pinch strength, return to work time, and complications were extracted and compared. All mean differences (MD) and odds ratios (OR) were expressed as ECTR relative to OCTR., Results: Our meta-analysis contained twenty-eight studies. ECTR was associated with significantly higher satisfaction rates (MD, 3.13; 95% confidence interval [CI], 1.43 to 4.82; P = 0.0003), greater key pinch strengths (MD, 0.79 kg; 95% CI, 0.27 to 1.32; P = 0.003), earlier return to work times (MD, - 7.25 days; 95% CI, - 14.31 to - 0.19; P = 0.04), higher transient nerve injury rates (OR, 4.87; 95% CI, 1.37 to 17.25; P = 0.01), and a lower incidence of scar-related complications (OR, 0.20; 95% CI, 0.07 to 0.59; P = 0.004). The permanent nerve injury showed no significant differences between the two methods (OR, 1.93; 95% CI, 0.58 to 6.40; P = 0.28)., Conclusions: Overall, evidence from randomized controlled trials indicates that ECTR results in better recovery of daily life functions compared to OCTR, as revealed by higher satisfaction rates, greater key pinch strengths, earlier return to work times, and fewer scar-related complications. Our findings suggest that patients with CTS can be effectively managed with ECTR.

Objective: External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI)., Methods: The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018., Results: A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1-47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44-50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0-1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6-87.1; p = 0.003)., Conclusions: The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Study Design: A retrospective, population-based study., Objectives: To identify factors affecting long-term mortality and medical resources use in disabled spinal cord injury (SCI) patients after syringomyelia diagnosis., Setting: A National Health Insurance Research Database containing 10,374 patients with SCI., Methods: Data recorded between 1997 and 2012 for 376 disabled SCI patients with syringomyelia and 376 characteristics-matched disabled SCI patients without syringomyelia were collected. The index date was the date of syringomyelia diagnosis. Cox proportional hazards regression model was used to investigate the factors affecting 10-year mortality in these patients. Medical resources use was compared for 1 year before and after index date., Results: The survival rate at 10-year follow-up after syringomyelia diagnosis was estimated at 68.6%. The 10-year survival rate was comparable between the two groups. Age ≥ 60 (adjusted hazard ratios (aHR) 4.21, 95% confidence interval (CI) 2.97 to 5.96) and < 30 years (aHR 0.25, 95% CI 0.10 to 0.62), spinal cord or spinal canal operations within 1 year after the index date (aHR 1.84, 95% CI 1.19 to 2.84), history of pneumonia (aHR 1.55, 95% CI 1.07 to 2.26), and history of coronary heart disease (CHD) (aHR 1.85, 95% CI 1.18 to 2.89) were significantly associated with long-term mortality. Outpatient prescription costs were higher during 1 year after the diagnosis than those of 1 year before the diagnosis., Conclusion: Age, spinal operations, history of pneumonia, and history of CHD are associated with 10-year mortality in disabled SCI patients with syringomyelia.

Background: Spine surgery is a demanding surgical specialty which requires surgeons to operate for hours on end, often compromising good posture. Sustained poor posture in the operating room (OR) can be the source of many adverse health effects on spine surgeons. This study will analyze posture of a spine surgeon in different types of spine surgery cases., Methods: Posture of a surgeon was measured using the UPRIGHT Posture Training Device. The device was worn by the surgeon in the OR through a wide variety of spine surgery cases., Results: The percent time spent slouched while performing cervical, adult deformity, and lumbar spine surgeries is 39.9, 58.9, and 38.6, respectively. For all surgeries recorded, the percent time slouched is 41.6. The average procedure time was 145.3 min, with adult deformity cases on average being the longest (245.6 min) followed by cervical (152.9 min) and then lumbar (122.5 min)., Conclusion: Poor posture while operating is very likely to occur for many spine surgeons regardless of case type. This poor posture is maintained for long periods of time given the average spine surgery procedure recorded in the study was roughly 2.5 h long. Spine surgeons should be aware of the tendency for poor posture while operating, and they should try using posture-improving techniques to maintain good spine health.

Introduction: The aim of this study was to describe core characteristics in a Danish population of rehabilitated traumatic spinal cord injury (SCI) patients., Methods: Retrospectively, data were extracted from a database on all traumatic patients with SCI admitted to the Spinal Cord Injury Centre of Western Denmark having sustained an injury to the spinal cord between 1 January 1997 and 1 January 2017. Age is presented as medians and interquartile ranges (IQR)., Results: A total of 584 (women = 122; men = 462) traumatic patients with SCI with a median age of 42.9 years (26.4-58.3 years) were identified of whom 390 underwent surgery (SG) and 55 were treated conservatively forming a conservative group (CG). The acute treatment regime was unknown in 139 patients with SCI. Patients in the CG were significantly older (median 63.6 years (IQR: 39.1-71.5) than patients in the SG (median 52.8 years (IQR: 37.2-67.2), p = 0.02). The relative risk (RR) of fractures was higher in the SG (RR = 2.74 (1.91-3.95), p less than 0.0001). The initial American Spinal Injury Association Impairment Scale (AIS) grades (A, B, C and D) differed significantly (Kruskal-Wallis test, p less than 0.02) with a higher frequency of AIS Din the CG. Fewer persons with a cervical than with a non-cervical level of injury underwent spinal surgery (RR = 0.65 (0.54-0.77), p less than 0.0004)., Conclusions: In a Danish population of patients with traumatic SCI, we observed a preponderance for surgical treatment among a) younger patients, b) patients with vertebral fractures, and c) more severe SCI cases., Funding: This study received no external funding., Trial Registration: The study was conducted in accordance with the Helsinki II Declaration. Data were obtained with permission from the Danish Data Protection Agency (record number 2012-41-0572)., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Purpose: To analyze the reasons and patient-related and injury-related risk factors for reoperation after surgery for acute subdural hematoma (SDH) and the effects of reoperation on treatment outcome., Methods: Among adult patients operated on for acute SDH between 2013 and 2017, patients reoperated within 14 days after the primary surgery were identified. In all patients, parameters were identified that related to the patient (age, anticoagulation, antiplatelet, and antiepileptic treatment, and alcohol intoxication), trauma (Glasgow Coma Score, SDH thickness, midline shift, midline shift /hematoma thickness rate, other surgical lesion, primary surgery-trephination, craniotomy, or decompressive craniotomy), and Glasgow Outcome Score (GOS). The reasons for reoperation and intervals between primary surgery and reoperation were studied., Results: Of 86 investigated patients, 24 patients were reoperated (27.9%), with a median interval of 2 days between primary surgery and reoperation. No significant differences in patients and injury-related factors were found between reoperated and non-reoperated patients. The rate of primary craniectomies was higher in non-reoperated patients (P = 0.066). The main indications for reoperation were recurrent /significant residual SDH (10 patients), contralateral SDH (5 patients), and expansive intracerebral hematoma or contusion (5 patients). The final median GOS was 3 in non-reoperated and 1.5 in reoperated patients, with good outcomes in 41.2% of non-reoperated and 16.7% of reoperated patients., Conclusions: Reoperation after acute SDH surgery is associated with a significantly worse prognosis. Recurrent /significant residual SDH and contralateral SDH are the most frequently found reasons for reoperation. None of the analyzed parameters were significant reoperation predictors.

Background: The purpose of this study is to examine the incidence, risk factors, and morbidity of postoperative urinary tract infections (UTI) in pediatric surgical patients., Methods: All patients in the 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Pediatric database were included. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of patient and procedure characteristics on the risk for UTI and to estimate the effects of UTI on the risk for readmission and reoperation., Results: Of 369,176 patients, 1964 (0.5%) developed a postoperative UTI. Those undergoing urological and neurosurgical procedures were at greatest risk. Diabetes, ventilator dependence, and dependence on nutritional support each increased the odds of developing a UTI by more than 60% (P < 0.01). On multivariable analysis, UTI was an independent risk factor for unplanned readmission (OR, 4.93; 95% CI, 4.39-5.54; P < 0.001) and reoperation (OR, 1.21; 95% CI, 1.01-1.45; P = 0.041)., Conclusion: Urinary tract infection is an uncommon but not inconsequential complication following surgery in the pediatric population and is associated with increased risk of readmission and reoperation. The identification of risk factors for postoperative UTI provides the opportunity for targeted surveillance and patient-specific interventions to prevent UTIs in children at greatest risk., Level of Evidence: Level III, retrospective comparative study., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Adults with traumatic brain injury (TBI) who present hypertensive suffer worse outcomes and increased mortality compared to normotensive patients. The purpose of this study is to determine if age-adjusted hypertension on presentation is associated with worsened outcomes in pediatric TBI., Methods: A retrospective chart review was conducted on pediatric patients with severe TBI admitted to a single system pediatric tertiary care center. The primary outcome was mortality. Secondary outcomes included length of stay, need for neurosurgical intervention, duration of mechanical ventilation, and the need for inpatient rehabilitation., Results: Of 150 patients, 70% were hypertensive and 30% were normotensive on presentation. Comparing both groups, no statistically significant differences were noted in mortality (13.3% for both groups), need for neurosurgical intervention (51.4% vs 48.8%, p = 0.776), length of stay (6 vs 8 days, p = 0.732), duration of mechanical ventilation (2 vs 3 days, p = 0.912), or inpatient rehabilitation rates (48.6% vs 48.9%, p = 0.972). In comparing just the hypertensive patients, there was a trend toward increased mortality in the 95th and 99th percentile groups at 15.8% and 14.1%, versus the 90th percentile group at 6.7% but the difference was not statistically significant (p = 0.701)., Conclusions: Contrary to the adult literature, pediatric patients with severe TBI and hypertension on presentation do not appear to have worsened outcomes compared to those who are normotensive. However, a trend toward increased mortality did exist at extremes of age adjusted hypertension. Larger scale studies are needed to validate these findings., Study Type: Retrospective cohort study LEVEL OF EVIDENCE: III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: For symptomatic nonsecreting pituitary adenomas (PAs), resection remains a critical option for treatment. In this study, the authors used a large-population national database to compare endoscopic surgery (ES) to nonendoscopic surgery (NES) for the surgical management of PA., Methods: The National Cancer Database was queried for all patients diagnosed with histologically confirmed PA who underwent resection between 2010 and 2016 in which the surgical approach was specified. Due to database limitations, microsurgery and craniotomy were both categorized as NES., Results: Of 30,488 identified patients, 16,373 (53.7%) underwent ES and 14,115 (46.3%) underwent NES. There was a significant increase in the use of ES over time (OR 1.16, p < 0.01). Furthermore, there was a significant temporal increase in ES approach for tumors ≥ 2 cm (OR 1.17, p < 0.01). Compared to NES, patients who underwent ES were younger (p = 0.01), were treated at academic centers (p < 0.01), lived a greater distance from their treatment site (p < 0.01), had smaller tumors (p < 0.01), had greater medical comorbidity burden (p = 0.04), had private insurance (p < 0.01), and had a higher household income (p < 0.01). After propensity score matching to control for age, tumor size, Charlson/Deyo score, and type of treatment center, patients who underwent ES had a shorter length of hospital stay (LOS) (3.9 ± 4.9 days vs 4.3 ± 5.4 days, p < 0.01), although rates of gross-total resection (GTR; p = 0.34), adjuvant radiotherapy (p = 0.41), and 90-day mortality (p = 0.45) were similar. On multivariate logistic regression, African American race (OR 0.85, p < 0.01) and tumor size ≥ 2 cm (OR 0.89, p = 0.01) were negative predictors of receiving ES, whereas diagnosis in more recent years (OR 1.16, p < 0.01), greater Charlson/Deyo score (OR 1.10, p = 0.01), receiving treatment at an academic institution (OR 1.67, p < 0.01) or at a treatment site ≥ 20 miles away (OR 1.17, p < 0.01), having private insurance (OR 1.09, p = 0.01), and having a higher household income (OR 1.11, p = 0.01) were predictive of receiving ES. Compared to the ES cohort, patients who started with ES and converted to NES (n = 293) had a higher ratio of nonwhite race (p < 0.01), uninsured insurance status (p < 0.01), longer LOS (p < 0.01), and higher rates of GTR (p = 0.04)., Conclusions: There is an increasing trend toward ES for PA resection including its use for larger tumors. Although ES may result in shorter LOS compared to NES, rates of GTR, need for adjuvant therapy, and short-term mortality may be similar. Factors such as tumor size, insurance status, facility type, income, race, and existing comorbidities may predict receiving ES.

Objective: Improved outcomes in patients with subarachnoid hemorrhage (SAH) treated at high-volume centers have been reported. The authors sought to examine whether hospital case volume and comprehensive stroke center (CSC) capabilities affect outcomes in patients treated with clipping or coiling for SAH., Methods: The authors conducted a nationwide retrospective cohort study in 27,490 SAH patients who underwent clipping or coiling in 621 institutions between 2010 and 2015 and whose data were collected from the Japanese nationwide J-ASPECT Diagnosis Procedure Combination database. The CSC capabilities of each hospital were assessed by use of a validated scoring system based on answers to a previously reported 25-item questionnaire (CSC score 1-25 points). Hospitals were classified into quartiles based on CSC scores and case volumes of clipping or coiling for SAH., Results: Overall, the absolute risk reductions associated with high versus low case volumes and high versus low CSC scores were relatively small. Nevertheless, in patients who underwent clipping, a high case volume (> 14 cases/yr) was significantly associated with reduced in-hospital mortality (Q1 as control, Q4 OR 0.71, 95% CI 0.55-0.90) but not with short-term poor outcome. In patients who underwent coiling, a high case volume (> 9 cases/yr) was associated with reduced in-hospital mortality (Q4 OR 0.69, 95% CI 0.53-0.90) and short-term poor outcomes (Q3 [> 5 cases/yr] OR 0.75, 95% CI 0.59-0.96 vs Q4 OR 0.65, 95% CI 0.51-0.82). A high CSC score (> 19 points) was significantly associated with reduced in-hospital mortality for clipping (OR 0.68, 95% CI 0.54-0.86) but not coiling treatment. There was no association between CSC capabilities and short-term poor outcomes., Conclusions: The effects of case volume and CSC capabilities on in-hospital mortality and short-term functional outcomes in SAH patients differed between patients undergoing clipping and those undergoing coiling. In the modern endovascular era, better outcomes of clipping may be achieved in facilities with high CSC capabilities.

Background: Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results., Methods: Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months., Results: We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors., Conclusions: Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.

Background: No standardized recommendations have been currently defined for anesthesia management of patients undergoing elective intracranial surgery. It can therefore be assumed that international clinical institutions have diverging approaches or standard operating procedures (SOP) which determine the type of general anesthesia, hemodynamic management, neuromuscular blockade, implementation of hypothermia and postoperative patient care., Objective: This international survey aimed to assess perioperative patient management during elective intracranial procedures. This survey was performed from February to October 2018 and 311 neurosurgical, maximum care centers across 19 European countries were contacted. The aim was to evaluate the anesthesia management to provide relevant data of neuroanesthesia practices across European centers. The survey differentiated between vascular and non-vascular as well as supratentorial and infratentorial procedures., Results: A total of 109 (35.0%) completed questionnaires from 15 European countries were analyzed. The results illustrated that total intravenous anesthesia was most commonly implemented during elective intracranial procedures (83.8%). All centers performed endotracheal intubation prior to major intracranial surgery (100%). Central venous lines were placed in 63.3% of cases. Moderate intraoperative hypothermia was carried out in 12.8% of the procedures, especially during vascular supratentorial and infratentorial surgery. A neuromuscular blockade during surgery was implemented in 74.1% of patients. Assessment of the neuromuscular junction was performed in 59.2% of cases, 76.7% of patients were immediately extubated in the operating room. 84.7% of these patients were directly transferred to a monitoring ward or an intensive care unit (ICU) and 55.1% of ventilated patients were transferred directly to an ICU., Conclusion: The data demonstrate that many aspects of anesthesia management during elective intracranial surgery vary between European institutions. The data also suggest that a broad consensus exists regarding the implementation of total intravenous anesthesia, airway management (endotracheal intubation), the implementation of urinary catheters, large bore peripheral venous lines and the broad availability of cross-matched red blood cell concentrates. Nevertheless, anesthesia management (e.g. central venous catheterization, moderate hypothermia, neuromuscular monitoring) is still handled differently across many European institutions. A lack of standardized guidelines defining anesthetic management in patients undergoing intracranial procedures could explain this variability. Further studies could help establish optimal anesthesia management for these patients. This in turn could help in the development of national and international guidelines and SOPs which could define optimal management strategies for intracranial procedures.

Backgound: Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States., Methods: Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management., Results: There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone., Conclusions: There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Standard follow-up care for patients with high-grade glioma (HGG) involves routine surveillance imaging to detect disease progression, assess treatment response, and monitor clinical symptoms. Although logical in nature, evidence supporting this practice is limited. We hypothesize patients with tumor recurrence detected on routine surveillance imaging will experience superior outcomes relative to symptomatic detection, using measures of survival and postrecurrence neurologic function., Methods: Adult patients receiving treatment for HGG at our institution from 2004 to 2018 were identified, and data including tumor characteristics, imaging results, neurologic status, and survival were extracted from the medical records of patients meeting inclusion criteria. All participants were followed for a minimum of 12 months, or for survival duration. Survival and neurologic function differences were assessed using log rank and 2-sample t tests with 2-sided 0.05 alpha level of significance., Results: Of the 74 patients meeting inclusion criteria, 47 (63.5%) had recurrence detected via routine surveillance imaging, and 27 (36.5%) had symptomatic detection outside of the surveillance schedule. Neither median overall survival (14.8 months for surveillance and 15.7 months for symptomatic; P = 0.600) nor postrecurrence neurologic function (assessed by Karnofsky Performance Scale Index and Eastern Cooperative Oncology Group) differed between the surveillance and symptomatic detection groups (P = 0.699 and P = 0.908, respectively)., Conclusions: Recurrence detection occurring via routine surveillance imaging did not yield superior patient outcomes relative to symptomatic detection occurring outside of the standard surveillance schedule in patients with HGG. Further evaluation of surveillance imaging and alternative follow-up methods for this patient population may be warranted., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: There is limited evidence on the comparative performance of private and public healthcare. Our aim was to compare outcomes following surgery for lumbar disc herniation (LDH) in private versus public hospitals., Methods: Data were obtained from the Norwegian registry for spine surgery. Primary outcome was change in Oswestry disability index (ODI) 1 year after surgery. Secondary endpoints were quality of life (EuroQol EQ-5D), back and leg pain, complications, and duration of surgery and hospital stays., Results: Among 5221 patients, 1728 in the private group and 3493 in the public group, 3624 (69.4%) completed 1-year follow-up. In the private group, mean improvement in ODI was 28.8 points vs 32.3 points in the public group (mean difference - 3.5, 95% CI - 5.0 to - 1.9; P for equivalence < 0.001). Equivalence was confirmed in a propensity-matched cohort and following mixed linear model analyses. There were differences in mean change between the groups for EQ-5D (mean difference - 0.05, 95% CI - 0.08 to - 0.02; P = 0.002) and back pain (mean difference - 0.2, 95% CI - 0.2, - 0.4 to - 0.004; P = 0.046), but after propensity matching, the groups did not differ. No difference was found between the two groups for leg pain. Complication rates was lower in the private group (4.5% vs 7.2%; P < 0.001), but after propensity matching, there was no difference. Patients operated in private clinics had shorter duration of surgery (48.4 vs 61.8 min) and hospital stay (0.7 vs 2.2 days)., Conclusion: At 1 year, the effectiveness of surgery for LDH was equivalent in private and public hospitals.

Study Design: Retrospective cohort study., Objective: To assess the rate, injury site, aetiology and outcomes in elective spinal surgery patients who sustained a spinal cord injury (SCI)., Setting: SCI national centre Toledo, Spain., Methods: The study sample included patients who sustained an SCI after elective spinal surgery from 2013 to 2017. Oncological patients and patients receiving interventional therapies were excluded. Data collected included: demographics, aetiology, precipitating cause, injury mechanism, injury site, neurological status (AIS), SCIMIII at admission and discharge, hypertension, diabetes mellitus, obesity, dyslipidemia, depression and hospital length of stay., Results: One thousand two hundred and eighty-two patients were admitted in this period of whom 114 met the inclusion criteria with a median (IQR) age of 58 (45-69) years; 46% female. The prevalence of SCI as a complication following spinal surgery in the total number of patients admitted to our centre was 9%. In 43%, the injury was to the dorsal spine with T12 being the most common neurological level of injury (20% of cases following laminectomy secondary to spinal canal stenosis). The most frequent precipitating cause was epidural haematoma (38% of cases). The median (IQR) SCIMIII scores at admission and discharge were (31) points (20-54) and (67) points (34-81), respectively. General AIS at admission were C (35%) and D at discharge (54%). The presence of hypertension, diabetes mellitus, obesity and dyslipidemia adjusted by age was not linked to a higher complication rate. The median (IQR) hospital length of stay was 120 days (60-189)., Conclusion: In total 8.9% of patients admitted with SCI were the result of elective spinal surgery.

Background: Level I trauma centers use patient triaging systems to deploy neurosurgical resources and pursue good outcomes; however, data describing the effectiveness these triage systems are lacking. We reviewed the leveling protocol (cases designated urgent and emergent) of a regional Level I trauma center to obtain epidemiologic data about the efficiency of that system and identify areas for improvement., Methods: We retrospectively reviewed leveled neurosurgical cases from January 2015 to October 2017, assessing surgery date, neurosurgical procedure, posted surgical urgency level (levels 1-3, with 1 being most urgent), and post-to-room (PTR) time (i.e., the time between initial leveling and admission of the patient to the operating room). Mean PTR times were compared between case types using one-way analysis of variance with post hoc Tukey honestly significant difference analysis., Results: Of 1469 cases, 577 (39.3%) were shunt placement or revision, 231 (15.7%) were craniectomy or craniotomy for hematoma, 147 (10.0%) were craniectomy or craniotomy for tumor, and 514 (35.0%) were for other indications. Among level 1 cases, PTR time was lowest for craniotomies to evacuate intracranial hematoma (mean 16.2 minutes) and highest for spinal decompression procedures and wound washouts (mean 36.2 and 42.4 minutes, respectively)., Conclusions: To our knowledge, this is the first study of variability in PTR timing as a function of surgical urgency or indication. The most common leveled cases were craniectomies or craniotomies to relieve increased intracranial pressure, which were also the most common level 1 cases. Significant variability occurred within each leveling category; thus, further investigation is required., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aim: To investigate the epidemiology of traumatic spinal cord injury (TSCI) in New Zealand over a 10-year period., Methods: Ambispective data of all new patients admitted to New Zealand's two spinal rehabilitation units between January 2007 and December 2016 (n=929) were collated. Variables assessed included age at injury, gender, ethnicity, date of injury, aetiology, length of hospital stay, injury level, neurological status on discharge and discharge destination., Results: The incidence of TSCI averaged 22 (95% CI 21-24) per million, increasing 6% a year. The average incidence for Māori (29 per million people (95% CI 25-34)) was 1.8 times higher than New Zealand European (16 per million people (95% CI 15-18)), and show an increase of 14% a year. The median age of TSCI increased from 43 to 48 years. Overall, falls (32%), transport (32%) and sports (22%) were the most common causes of TSCI. Cervical TSCI (54%) were most common, particularly in older adults (70% over 75 years) and Māori (61%) and Pacific Island (72%) patients. Surgical rates remained stable (77%) but length of stay in hospital decreased over the study period., Conclusions: The demographic of TSCI is changing in New Zealand. The median age of patients is increasing, as is the incidence, particularly for women, older adults and Māori patients., Competing Interests: Mrs Croot is one of two NZ Spinal Cord Injury Registry (NZSCIR) Coordinators. She is involved with consenting participants, data collection, data entry, registry oversight and maintenance, as well as data access requests for the NZSCIR. She was not involved in the data extraction for this paper. Dr Nunnerley reports funding from Canterbury Orthopaedic Services during the conduct of the study.

Importance: Palliative care has the potential to improve care for patients and families undergoing high-risk surgery., Objective: To characterize the use of perioperative palliative care and its association with family-reported end-of-life experiences of patients who died within 90 days of a high-risk surgical operation., Design, Setting, and Participants: This secondary analysis of administrative data from a retrospective cross-sectional patient cohort was conducted in the Department of Veterans Affairs (VA) Healthcare System. Patients who underwent any of 227 high-risk operations between January 1, 2012, and December 31, 2015, were included., Exposures: Palliative-care consultation within 30 days before or 90 days after surgery., Main Outcomes and Measures: The outcomes were family-reported ratings of overall care, communication, and support in the patient's last month of life. The VA surveyed all families of inpatient decedents using the Bereaved Family Survey, a valid and reliable tool that measures patient and family-centered end-of-life outcomes., Results: A total of 95 204 patients underwent high-risk operations in 129 inpatient VA Medical Centers. Most patients were 65 years or older (69 278 [72.8%]), and the most common procedures were cardiothoracic (31 157 [32.7%]) or vascular (23 517 [24.7%]). The 90-day mortality rate was 6.0% (5740 patients) and varied by surgical subspecialty (ranging from 278 of 7226 [3.8%] in urologic surgery to 875 of 6223 patients [14.1%] in neurosurgery). A multivariate mixed model revealed that families of decedents who received palliative care were 47% more likely to rate overall care in the last month of life as excellent than those who did not (odds ratio [OR], 1.47 [95% CI, 1.14-1.88]; P = .007), after adjusting for patient's characteristics, surgical subspecialty of the high-risk operation, and survey nonresponse. Similarly, families of decedents who received palliative care were more likely to rate end-of-life communication (OR, 1.43 [95% CI, 1.09-1.87]; P = .004) and support (OR, 1.31 [95% CI, 1.01-1.71]; P = .05) components of medical care as excellent. Of the entire cohort, 3374 patients (3.75%) had a palliative care consultation, and 770 patients (0.8%) received it before surgery. Of all decedents, 1632 (29.9%) had a palliative care consultation, with 319 (5.6%) receiving it before surgery., Conclusions and Relevance: Receipt of a palliative consultation was associated with better ratings of overall end-of-life care, communication, and support, as reported by families of patients who died within 90 days of high-risk surgery. Yet only one-third of decedents was exposed to palliative care. Expanding integration of perioperative palliative care may benefit patients undergoing high-risk operations and their families.

Continuous data that are not normally distributed are typically presented in terms of median and interquartile range (IQR) for each group. High-quality anesthesia journals often require that confidence intervals are calculated and presented for all estimated associations of interest reported within a manuscript submission, and therefore, methods for calculating confidence intervals for differences in medians are vital. It is informative to present the difference in medians along with a confidence interval to provide insight about the magnitude of variability for the estimated difference. In a clinical research example using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric database, we demonstrate how to estimate confidence intervals for the difference in medians using 3 different statistical methods: the Hodges-Lehmann estimator, bootstrap resampling with replacement, and quantile regression modeling on the median (median regression). We discuss specific recommendations regarding the methods according to the objectives of the study as well as the distribution of the data as it pertains to the assumptions of the respective methods. Quantile regression allows for covariate adjustment, which may be an advantage in situations where differences in medians between groups may be due to confounding.

Objective: To profile European trends in pediatric epilepsy surgery (<16 years of age) between 2008 and 2015., Methods: We collected information on volumes and types of surgery, pathology, and seizure outcome from 20 recognized epilepsy surgery reference centers in 10 European countries., Results: We analyzed retrospective aggregate data on 1859 operations. The proportion of surgeries significantly increased over time (P < .0001). Engel class I outcome was achieved in 69.3% of children, with no significant improvement between 2008 and 2015. The proportion of histopathological findings consistent with glial scars significantly increased between the ages of 7 and 16 years (P for trend = .0033), whereas that of the remaining pathologies did not vary across ages. A significant increase in unilobar extratemporal surgeries (P for trend = .0047) and a significant decrease in unilobar temporal surgeries (P for trend = .0030) were observed between 2008 and 2015. Conversely, the proportion of multilobar surgeries and unrevealing magnetic resonance imaging cases remained unchanged. Invasive investigations significantly increased, especially stereo-electroencephalography. We found different trends comparing centers starting their activity in the 1990s to those whose programs were developed in the past decade. Multivariate analysis revealed a significant variability of the proportion of the different pathologies and surgical approaches across countries, centers, and age groups between 2008 and 2015., Significance: Between 2008 and 2015, we observed a significant increase in the volume of pediatric epilepsy surgeries, stability in the proportion of Engel class I outcomes, and a modest increment in complexity of the procedures., (Wiley Periodicals, Inc. © 2019 International League Against Epilepsy.)

Introduction : Deep brain stimulation (DBS) is a well-established treatment of movement disorders; but recently there has been an increasing trend toward the ablative procedure magnetic resonance-guided focused ultrasound (MRgFU). DBS is an efficient neuromodulatory technique but associated with surgical complications. MRIgFUS is an incision-free method that allows thermal lesioning, with fewer surgical complications but irreversible effects. Areas covered : We look at current and prospective aspects of both techniques. In DBS, appropriate patient selection, improvement in surgical expertise, target accuracy (preoperative and intraoperative imaging), neurophysiological recordings, and novel segmented leads need to be considered. However, increased number of older patients with higher comorbidities and risk of DBS complications (mainly intracranial hemorrhage, but also infections, hardware complications) make them not eligible for surgery. With MRgFUS, hemorrhage risks are virtually nonexistent, infection or hardware malfunction are eliminated, while irreversible side effects can appear. Expert commentary : Comparison of the efficacy and risks associated with these techniques, in combination with a growing aged population in developed countries with higher comorbidities and a preference for less invasive treatments, necessitates a review of the indications for movement disorders and the most appropriate treatment modalities.

Objective: Quality indicators are emerging as tools to evaluate health care outcomes. Few studies have evaluated indicators suitable for neurosurgery so far. Among others, reoperation rate has been suggested as a possible indicator. We aimed to evaluate the reoperation rate in a large neurosurgery adult collective., Methods: In this exploratory post hoc analysis, we evaluated all patients operated in our service for elective and emergency surgery between January 2014 and May 2016. Planned and unplanned reoperations were filtered and a quantitative analysis, including uni- and multivariate analyses, was performed., Results: A total of 3760 patients were included in this evaluation. From 378 reoperated patients within 30 days (10.1%), 51 underwent planned procedures (1.4%). Three hundred twenty-seven patients (8.7%) represented the analyzed collective of patients having undergone unplanned surgical procedures, causing a total of 409 from 4268 additional procedures (9.6%). Early unplanned 7-day reoperation rate was 4.5% (n = 193), occurring in 4.5% of patients (n = 193). Postoperative hemorrhage (n = 107, 26.2%) and external ventricle drainage-associated infections or dislocation (n = 105, 25.7 %) were the most common indication for unplanned surgery., Conclusion: Unplanned re-operation rate of a neurosurgical service can help to internally evaluate health care outcome and improve quality of care. Benchmarking with this indicator however is not recommendable as results can vary distinctly due to the heterogenic patient collective of each institution. We expect unplanned reoperation rates to be higher in large university hospitals and tertiary centers with complex cases, as compared to center with less complex cases treating patients with lower morbidity. In this study, we deliver an authentic portrait of a large neurosurgical center in Germany.