Category: meta-analysis

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Skip Laminectomy Compared with Laminoplasty for Cervical Compressive Myelopathy

World Neurosurg. (2018) 120:296-301

This meta-analysis evaluated the clinical outcomes of skip laminectomy relative to laminoplasty for the treatment of cervical compressive myelopathy.

METHODS: The Cochrane library, PubMed MEDLINE, EMBASE, and Web of Science databases were comprehensively searched to identify relevant articles published up to March 18, 2018. All values of weighted mean difference (WMD) or odds ratio are expressed as skip laminectomy relative to laminoplasty.

RESULTS: Four studies comprising 241 patients were included. Skip laminectomy and laminoplasty were comparable in terms of cervical lordotic curvature (weighted mean difference [WMD] L2.37; 95% confidence interval [CI] L6.18 to 1.43; P [ 0.22) and range of motion (WMD e2.65; 95% CI L6.02 to 0.72; P [ 0.12). The pooled data revealed that the mean visual analogue scale score for pain of the skip laminectomy group was significantly lower than that of the laminoplasty group (WMD e0.97; 95% CI L1.90 to L0.05; P [ 0.04), and the rate of axial pain was also significantly lower (WMD 0.26; 95% CI 0.07e0.93; P [ 0.04). The atrophy rates of the deep extensor muscles in the skip laminectomy group (14%) were significantly lower than that of the laminoplasty group (60%).

CONCLUSIONS: This meta-analysis determined that skip laminectomy was superior to laminoplasty in terms of visual analogue scale score and rates of axial pain and muscle atrophy. These results warrant further confirmation in future research.

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Coiling Versus Microsurgical Clipping in the Treatment of Unruptured Middle Cerebral Artery Aneurysms: A Meta-Analysis

Neurosurgery 83:879–889, 2018

Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. OBJECTIVE: To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis.

METHODS: A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed.

RESULTS: Thirty-seven studies including 3352 patients were included. Using the randomeffects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different.

CONCLUSION: This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

 

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Open-versus French-Door Laminoplasty for the Treatment of Cervical Multilevel Compressive Myelopathy: A Meta-Analysis

World Neurosurg. (2018) 117:129-136

OBJECTIVE: To compare the clinical outcomes and postoperative complications between open-door laminoplasty (ODL) versus French-door laminoplasty (FDL) for the treatment of cervical multilevel compressive myelopathy.

METHODS: We comprehensively searched PubMed, EMBASE, Cochrane library, and China National Knowledge Infrastructure to identify relevant articles. The search results were last updated on January 1, 2018. All values of weighted mean difference (WMD) and odds ratio are expressed as ODL relative to FDL.

RESULTS: Six studies containing 430 patients were included in our metaanalysis. In randomized controlled trials, there was no significant difference in Japanese Orthopaedic Association (JOA) scores between ODL and FDL groups (WMD, 0.06; 95% confidence limits [CL], e0.52 to 0.64; P [ 0.84). However, in the retrospective trials, JOA scores were significantly higher in the ODL group than in the FDL group (WMD, 0.95; 95% CL, 0.55e1.34; P < 0.05). The pooled data showed that the magnitude of spinal canal expansion in the ODL group was higher than in the FDL group (WMD, 24.39%; 95% confidence interval, 12.33e36.45; P < 0.05).

CONCLUSIONS: The present meta-analysis showed that the magnitude of canal expansion was higher with ODL than with FDL. There is a lack of compelling evidence to prove the superiority of one procedure over the other.

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Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries

World Neurosurg. (2018) 114:391-407

Minimally invasive surgery (MIS) techniques have emerged as viable and safe alternatives for lumbar disc herniation, including percutaneous discectomy, percutaneous endoscopic discectomy, and tubulardiscectomy (TD). We present here a systematic review and a multiple-treatment metaanalysis evaluating the operative outcomes and patient-reported outcomes of open/microdiscectomy (OD/MD) and all MIS approaches for lumbar disc herniation.

METHODS: The PICO approach and PRISMA (i.e., Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to query existing online databases since their inception to 2016, which yielded 14 studies after we applied the inclusion/exclusion criteria. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials was used to assess the risk of bias in each study was used to assess the risk of bias in each study. Each outcome was assessed across all studies with the GRADE (i.e., Grading of Recommendations, Assessment, Development and Evaluations) criteria.

RESULTS: There were 1707 patients analyzed, with 782 (45.81%) undergoing OD/MD, 491 (28.76%) undergoing TD, 199 (11.65%) undergoing percutaneous endoscopic discectomy, and 235 (13.76%) patients undergoing percutaneous discectomy. TD was found to be associated with significantly worse Oswestry Disability Index scores (mean difference 1.17, P [ 0.03) whereas OD/MD was associated with worse Oswestry Disability Index scores compared with all other approaches (mean difference 2.61, P [ 0.03), significantly longer duration of stay (mean difference 2.96, P [ 0.04), and more blood loss (mean difference 30.53, P < 0.001). In terms of complications, TD was found to be associated with a greater rate of overall complications (odds ratio [OR] 1.49, P [ 0.002), greater incidence of dural tears (OR 1.72 P [ 0.04), and recurrent herniation (OR 2.09, P [ 0.0007). Finally, OD/MD was associated with significantly lower incidence of revision surgery (OR 0.53, P [ 0.0007).

CONCLUSIONS: Our meta-analysis revealed that tubular-discectomy and percutaneous-endoscopic-discectomy, the most commonly employed MIS techniques for discectomy, can be used as safe alternatives for open discectomy depending on the preference of the operating surgeon.

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Modified Laminoplasty Preserving the Posterior Deep Extensor Insertion into C2 Improves Clinical and Radiologic Results Compared with Conventional Laminoplasty: A Meta-Analysis

World Neurosurg. (2018) 111:157-165

Whether modified laminoplasty is better than conventional laminoplasty is unclear. Thus, a meta-analysis comparing the outcomes of preserving or repairing the posterior deep extensor insertion to C2 in laminoplasty was conducted for patients with multilevel cervical spondylotic myelopathy (MCSM).

METHODS: Several electronic databases were chosen to search for relevant studies. The primary indices included preoperative and postoperative Japanese Orthopaedic Association (JOA) scores, JOA recovery rate, muscle atrophy rate, preoperative and postoperative range of motion (ROM), ROM decrease rate, and incidence of axial pain. Results are expressed as odds ratios with 95% confidence intervals for the dichotomous outcomes and mean differences for continuous outcomes.

RESULTS: Eight studies involving 763 patients were included in this study. The postoperative cervical ROM was significantly higher in the modified group (P [ 0.01, MD [ 3.0 [0.66, 5.35]), as was the cervical posterior muscle volume (P [ 0.02, MD [ 28.28 [4.42, 52.3]) and the operation time (MD [ L45.04, 95% CI L49.79, L40.29; P < 0.01). The incidence of axial symptoms in the modified group was lower than that in the conventional group (P < 0.01, OR 0.28 [0.17, 0.46]), as was the rate of decrease of cervical ROM (P [ 0.004, MD [ L6.72 [L11.25, 2.19]). There was no significant difference (P > 0.05) between the groups in blood loss, preoperative and postoperative JOA score, or JOA recovery rate.

CONCLUSIONS: Modified laminoplasty had shorter operation times, a lower incidence of axial pain, a higher cervical ROM, and a lower atrophy rate compared with conventional laminoplasty. The clinical and radiologic results of modified laminoplasty have been partly superior to those of conventional laminoplasty to date.

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Risk Factors for Recollapse of the Augmented Vertebrae After Percutaneous Vertebral Augmentation: A Systematic Review and Meta-Analysis

World Neurosurg. (2018) 111:119-129

Recollapse of the augmented vertebrae after percutaneous vertebral augmentation treatment for osteoporotic vertebral compression fractures has obtained much attention. Although many potential risk factors have been proposed, they are still disputed. The aim of our study was to identify the characteristics of the augmented vertebrae that had undergone a recollapse according to a systematic review from the earliest available records up to August 2017 and then conduct a meta-analysis based on eligible studies to assess significant potential risk factors for recollapse of the augmented vertebrae.

METHODS: Fourteen studies were identified for investigating recollapse of the augmented vertebrae. Of those studies, 9 studies were eligible for metaanalysis.

RESULTS: Pooled results showed that 5 primary factors were associated with recollapse of the augmented vertebrae, including preoperative intravertebral cleft, the affected vertebrae in the thoracolumbar region, preoperative severe kyphotic deformity, solid lump cement distribution pattern, and higher vertebral height restoration. It was possibly another risk factor that the distance between PMMA and superior end plate was relatively large.

CONCLUSIONS: Careful observation of patients with these risk factors and reasonable intervention could be useful to prevent deterioration of their clinical course

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Minimally Invasive Transforaminal Lumbar Interbody Fusion: Meta-analysis of the Fusion Rates. What is the Optimal Graft Material?

Neurosurgery 81:958–971, 2017

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is an increasingly popular procedure with several potential advantages over traditional open TLIF.

OBJECTIVE: The current study aimed to compare fusion rates of different graft materials used in MIS-TLIF, via meta-analysis of the published literature.

METHODS: A Medline search was performed and a database was created including patient’s type of graft, clinical outcome, fusion rate, fusion assessment modality, and duration of follow-up. Meta-analysis of the fusion rate was performed using StatsDirect software (StatsDirect Ltd, Cheshire, United Kingdom).

RESULTS: A total of 1533 patients from 40 series were included. Fusion rates were high, ranging from 91.8% to 99%. The imaging modalities used to assess fusion were computed tomography scans (30%) and X-rays (70%). Comparison of all recombinant human bone morphogenetic protein (rhBMP) series with all non-rhBMP series showed fusion rates of 96.6% and 92.5%, respectively. The lowest fusion rate was seen with isolated use of autologous local bone (91.8%). The highest fusion ratewas observed with combination of autologous local bone with bone extender and rhBMP (99.1%). The highest fusion rate without the use ofBMPwas seen with autologous local bone+bone extender (93.1%). The reported complication rate ranged from 0% to 35.71%. Clinical improvement was observed in all studies.

CONCLUSION: Fusion rates are generally high with MIS-TLIF regardless of the graft material used. Given the potential complications of iliac bone harvesting and rhBMP, use of other bone graft options for MIS-TLIF is reasonable. The highest fusion rate without the use of rhBMP was seen with autologous local bone plus bone extender (93.1%).

 

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Effect of statin treatment on vasospasm-related morbidity and functional outcome in patients with aneurysmal subarachnoid hemorrhage

J Neurosurg 127:291–301, 2017

The efficacy of statin therapy in treating aneurysmal subarachnoid hemorrhage (SAH) remains controversial. In this meta-analysis, the authors investigated whether statin treatment significantly reduced the incidence of cerebral vasospasm and delayed neurological deficits, promoting a better outcome after aneurysmal SAH.

METHODS: A literature search of the PubMed, Ovid, and Cochrane Library databases was performed for randomized controlled trials (RCTs) and prospective cohort studies investigating the effect of statin treatment. The end points of cerebral vasospasm, delayed ischemic neurological deficit (DIND), delayed cerebral infarction, mortality, and favorable outcome were statistically analyzed.

RESULTS Six RCTs and 2 prospective cohort studies met the eligibility criteria, and a total of 1461 patients were included. The meta-analysis demonstrated a significant decrease in the incidence of cerebral vasospasm (relative risk [RR] 0.76, 95% confidence interval [CI] 0.61–0.96) in patients treated with statins after aneurysmal SAH. However, no significant benefit was observed for DIND (RR 0.88, 95% CI 0.70–1.12), delayed cerebral infarction (RR 0.66, 95% CI 0.33–1.31), mortality (RR 0.69, 95% CI 0.39–1.24) or favorable outcome, according to assessment by the modified Rankin Scale or Glasgow Outcome Scale (RR 0.99, 95% CI 0.92–1.17).

CONCLUSIONS Treatment with statins significantly decreased the occurrence of vasospasm after aneurysmal SAH. The incidence of DIND, delayed cerebral infarction, and mortality were not affected by statin treatment. Future research should focus on DIND and how statins influence DIND.

 

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Lumbar Spinal Stenosis Associated With Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-analysis of Secondary Fusion Rates Following Open vs Minimally Invasive Decompression

Neurosurgery 80:355–367, 2017

Decompression without fusion is a treatment option in patients with lumbar spinal stenosis (LSS) associated with stable low-grade degenerative spondylolis- thesis (DS). A minimally invasive unilateral laminotomy (MIL) for “over the top” decom- pression might be a less destabilizing alternative to traditional open laminectomy (OL). OBJECTIVE: To review secondary fusion rates after open vs minimally invasive decom- pression surgery.

METHODS: We performed a literature search in Pubmed/MEDLINE using the keywords “lumbar spondylolisthesis” and “decompression surgery.” All studies that separately reported the outcome of patients with LSS+DS that were treated by OL or MIL (transmuscular or subperiosteal route)were included in our systematic review and meta-analysis. The primary end point was secondary fusion rate. Secondary end points were total reoperation rate, postoperative progression of listhetic slip, and patient satisfaction.

RESULTS: We identified 37 studies (19 with OL, 18 with MIL), with a total of 1156 patients, that were published between 1983 and 2015. The studies’evidence was mostly level 3 or 4. Secondary fusion rates were 12.8% after OL and 3.3% after MIL; the total reoperation rates were 16.3% after OL and 5.8% after MIL. In the OL cohort, 72% of the studies reported a slip progression compared to 0% in the MIL cohort, respectively. After OL, satisfactory outcome was 62.7% compared to 76% after MIL.

CONCLUSION: In patients with LSS and DS, minimally invasive decompression is associated with lower reoperation and fusion rates, less slip progression, and greater patient satisfaction than open surgery.

 

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Agents for fluorescence-guided glioma surgery: a systematic review of preclinical and clinical results

Acta Neurochir (2017) 159:151–167

Fluorescence-guided surgery (FGS) is a technique used to enhance visualization of tumor margins in order to increase the extent of tumor resection in glioma surgery. In this paper, we systematically review all clinically tested fluorescent agents for application in FGS for glioma and all pre-clinically tested agents with the potential for FGS for glioma.

Methods: We searched the PubMed and Embase databases for all potentially relevant studies through March 2016. We assessed fluorescent agents by the following outcomes: rate of gross total resection (GTR), overall and progression-free survival, sensitivity and specificity in discriminating tumor and healthy brain tissue, tumor-to-normal ratio of fluorescent signal, and incidence of adverse events.

Results: The search strategy resulted in 2155 articles that were screened by titles and abstracts. After full-text screening, 105 articles fulfilled the inclusion criteria evaluating the following fluorescent agents: 5-aminolevulinic acid (5-ALA) (44 studies, including three randomized control trials), fluorescein (11), indocyanine green (five), hypericin (two), 5- aminofluorescein-human serum albumin (one), endogenous fluorophores (nine) and fluorescent agents in a pre-clinical testing phase (30). Three meta-analyses were also identified.

Conclusions: 5-ALA is the only fluorescent agent that has been tested in a randomized controlled trial and results in an improvement of GTR and progression-free survival in high-grade gliomas. Observational cohort studies and case series suggest similar outcomes for FGS using fluorescein. Molecular targeting agents (e.g., fluorophore/nanoparticle labeled with anti-EGFR antibodies) are still in the pre-clinical phase, but offer promising results and may be valuable future alternatives.

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Seizures in supratentorial meningioma: a systematic review and meta-analysis

Meningiomas in Pregnancy- A Clinicopathologic Study of 17 Cases

J Neurosurg 124:1552–1561, 2016

Meningioma is the most common benign intracranial tumor, and patients with supratentorial meningioma frequently suffer from seizures. The rates and predictors of seizures in patients with meningioma have been significantly under-studied, even in comparison with other brain tumor types. Improved strategies for the prediction, treatment, and prevention of seizures in patients with meningioma is an important goal, because tumor-related epilepsy significantly impacts patient quality of life.

Methods: The authors performed a systematic review of PubMed for manuscripts published between January 1980 and September 2014, examining rates of pre- and postoperative seizures in supratentorial meningioma, and evaluating potential predictors of seizures with separate meta-analyses.

Results: The authors identified 39 observational case series for inclusion in the study, but no controlled trials. Preoperative seizures were observed in 29.2% of 4709 patients with supratentorial meningioma, and were significantly predicted by male sex (OR 1.74, 95% CI 1.30–2.34); an absence of headache (OR 1.77, 95% CI 1.04–3.25); peritumoral edema (OR 7.48, 95% CI 6.13–9.47); and non–skull base location (OR 1.77, 95% CI 1.04–3.25). After surgery, seizure freedom was achieved in 69.3% of 703 patients with preoperative epilepsy, and was more than twice as likely in those without peritumoral edema, although an insufficient number of studies were available for formal meta-analysis of this association. Of 1085 individuals without preoperative epilepsy who underwent resection, new postoperative seizures were seen in 12.3% of patients. No difference in the rate of new postoperative seizures was observed with or without perioperative prophylactic anticonvulsants.

Conclusions: Seizures are common in supratentorial meningioma, particularly in tumors associated with brain edema, and seizure freedom is a critical treatment goal. Favorable seizure control can be achieved with resection, but evidence does not support routine use of prophylactic anticonvulsants in patients without seizures. Limitations associated with systematic review and meta-analysis should be considered when interpreting these results.

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Microendoscopic discectomy versus open discectomy for lumbar disc herniation: a meta-analysis

Complications of endoscopic microdiscectomy using the EASYGO! system

Eur Spine J (2016) 25:1373–1381

Purpose: To compare the outcomes of microendoscopic discectomy and open discectomy for patients with lumbar disc herniation.

Methods: An extensive search of studies was performed in PubMed, Medline, Embase, Cochrane library and Google Scholar. The following outcome measures were extracted: visual analogue scale (VAS), Oswestry disability index (ODI), complication, operation time, blood loss and length of hospital stay. Data analysis was conducted with RevMan 5.0.

Results: Five randomized controlled trials involving 501 patients were included in this meta-analysis. The pooled analysis showed that there was no significant difference in the VAS, ODI or complication between the two groups. However, compared with the open discectomy, the microendoscopic discectomy was associated with less blood loss [WMD = -151.01 (-288.22, -13.80), P = 0.03], shorter length of hospital stay [WMD = -69.33 (-110.39, -28.28), P = 0.0009], and longer operation time [WMD = 18.80 (7.83, 29.76), P = 0.0008].

Conclusions: Microendoscopic discectomy, which requires a demanding learning curve, may be a safe and effective alternative to conventional open discectomy for patients with lumbar disc herniation.

 

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Predictors of Outcome Following Cerebral Aqueductoplasty

Cerebral Aqueductoplasty

Neurosurgery 78:285–296, 2016

The evidence supporting the efficacy and safety of cerebral aqueductoplasty (CA) is limited to small surgical series.

OBJECTIVE: To perform an individual participant data meta-analysis to determine the efficacy and safety of CA and to determine the effect of patient’s age, etiology, surgical approach, and use of stent on success.

METHODS: Electronic databases (MEDLINE, EMBASE, and CINAHL) were searched with no language or date restrictions to identify cohort studies of consecutive participants undergoing CA (without concomitant endoscopic third ventriculostomy or cerebrospinal fluid [CSF] shunt) that reported outcome. Outcome was defined as the time elapsed from the index operation until a second procedure was performed for CSF diversion.

RESULTS: Of 146 citations, 14 articles reporting on 137 participants were eligible. One hundred three participants (75%) did not require a second CSF diversion procedure. The mean duration until repeat CSF diversion procedure was 121.6 months (95% confidence interval [CI], 102.2-141.0). In multivariate analysis, older age at surgery (hazard ratio [HR], 0.43; 95% CI, 0.21-0.88; P = .020), congenital etiology (HR, 0.18; 95% CI, 0.04-0.85; P = .030), and use of stent (HR, 0.30; 95% CI, 0.13-0.70; P = .006) were independent predictors of good outcome. Morbidity, mainly ophthalmoparesis and hemorrhage, was experienced in 22% of participants.

CONCLUSION: Small retrospective cohort studies are inherently prone to biases, some of which are overcome through the use of individual participant data. The best available evidence suggests that CA is an effective procedure with a moderate morbidity profile. Older age at surgery, congenital etiology, and use of stent predict a good outcome with respect to delaying the requirement for a second CSF diversion procedure.

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Surgical Outcomes for Minimally Invasive vs Open Transforaminal Lumbar Interbody Fusion

tlif-x-ray-lat

Neurosurgery 77:847–874, 2015

Minimally invasive transforaminal lumbar interbody fusion (TLIF)—or MI-TLIF—has been increasing in prevalence compared with open TLIF (O-TLIF) procedures. The use of MI-TLIF is an evolving technique with conflicting reports in the literature about outcomes.

OBJECTIVE: To investigate the impact of MI-TLIF in comparison with O-TLIF for early and late outcomes by using the Visual Analog Scale for back pain (VAS-back) and the Oswestry Disability Index (ODI). Secondary end points include blood loss, operative time, radiation exposure, length of stay, fusion rates, and complications between the 2 procedures.

METHODS: During August 2014, a systematic literature search was performed identifying 987 articles. Of these, 30 met inclusion criteria. A random-effects meta-analysis was performed by using both pooled and subset analyses based on study type.

RESULTS: Our meta-analysis demonstrated that MI-TLIF reduced blood loss (P < .001), length of stay (P < .001), and complications (P = .001) but increased radiation exposure (P < .001). No differences were found in fusion rate (P = .61) and operative time (P = .34). A decrease in late VAS-back scores was demonstrated for MI TLIF (P < .001), but no differences were found in early VAS-back, early ODI, and late ODI.

CONCLUSION: MI-TLIF is associated with reduced blood loss, decreased length of stay, decreased complication rates, and increased radiation exposure. The rates of fusion and operative time are similar between MI-TLIF and O-TLIF. Differences in long-term outcomes in MI-TLIF vs O-TLIF are inconclusive and require more research, particularly in the form of large, multi-institutional prospective randomized controlled trials.

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Treatment strategies for dissecting aneurysms of the posterior cerebral artery

Treatment strategies for dissecting aneurysms of the posterior cerebral arteryActa Neurochir (2015) 157:1623–1632

We conducted a systematic review of the literature to evaluate the safety and efficacy of surgical treatment of previously coiled aneurysms.

Methods A comprehensive review of the literature for studies on surgical treatment of previously coiled aneurysms was conducted. For each study, the following data were extracted: patient demographics, initial clinical status, location and size of aneurysms, time interval between initial/last endovascular procedure and surgery, surgical indications, and microsurgical technique.We performed subgroup analyses to compare direct clipping versus coil removal and clipping versus parent vessel occlusion, early (<4 weeks post-coiling) versus late surgery and anterior versus posterior circulation.

Results Twenty-six studies with 466 patients and 471 intracranial aneurysms were included. All of the studies were retrospective and non-comparative case-series. Patients undergoing direct clipping had lower perioperative morbidity (5.0 %, 95%CI=2.6–7.4 %) when compared to those undergoing coil removal and clipping (11.1 %, 95 % CI=5.3–17.0 %) or parent vessel occlusion (13.1 %, 95%CI=4.6–21.6 %) (p=0.05). Patients receiving early surgery (<4 weeks post-coiling) had significantly lower rates of good neurological outcome (77.1 %, 95 % CI=69.3–84.8 %) when compared to those undergoing late surgery (92.1 %, 95 % CI=89.0–95.2 %) (p<0.01). There were higher rates of long-term neurological morbidity in the posterior circulation group (23.1 vs. 4.7 %, p<0.01) as well as long-term neurological mortality (4.4 vs. 2.8 %, p<0.01).

Conclusions Our meta-analysis suggests that surgical treatment is safe and effective. Our data indicate that aneurysms that are amenable to direct clipping have superior outcomes. Late surgery was also associated with better clinical outcomes. Surgery of recurrent posterior circulation aneurysms was associated with high rates of morbidity and mortality. Given the characteristics of the included studies, the quality of evidence of this meta-analysis is limited.

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A Systematic Review of the Treatment of Geriatric Type II Odontoid Fractures

Type II Odontoid Fractures

Neurosurgery 77:S6–S14, 2015

Odontoid fractures are the most common cervical spine fracture in the geriatric population; however, the treatment of type II odontoid fractures in this age group is controversial.

OBJECTIVE: To compare the short-term (<3 months) mortality, long-term (≥12 months) mortality, and complication rates of patients >60 years of age with a type II odontoid fracture managed either operatively or nonoperatively.

METHODS: We performed a systematic review of literature published between January 1, 2000, and February 1, 2015, related to the treatment of type II odontoid fractures in patients .60 years of age. An analysis of short-term mortality, long-term mortality, and the occurrence of complications was performed.

RESULTS: A total of 452 articles were identified, of which 21 articles with 1233 patients met the inclusion criteria. Short-term mortality (odds ratio, 0.43; 95% confidence interval, 0.30-0.63) and long-term mortality (odds ratio, 0.47; 95% confidence interval, 0.34-0.64) were lower in patients who underwent surgical treatment than in those who had nonsurgical treatment, and there were no significant differences in the rate of complications (odds ratio, 1.01; 95% confidence interval, 0.63-1.63). Surgical approach (posterior vs anterior) showed no significant difference in mortality or complication rate. Similarly, no difference in mortality or complication rate was identified with hard collar or a halo orthosis immobilization.

CONCLUSION: The current literature suggests that well-selected patients >60 years of age undergoing surgical treatment for a type II odontoid fracture have a decreased risk of short-term and long-term mortality without an increase in the risk of complications.

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Diagnostic Value and Safety of Brain Biopsy in Patients With Cryptogenic Neurological Disease: A Systematic Review and Meta-analysis of 831 Cases

Brain_biopsy_under_stereotaxy

Neurosurgery 77:283–295, 2015

The role of brain biopsy in patients with cryptogenic neurological disease is uncertain.

OBJECTIVE: To determine the risks and benefits of diagnostic brain biopsy for nonneoplastic indications in immunocompetent patients.

METHODS: Appropriate studies were identified by searching electronic databases.

RESULTS: We screened 3645 abstracts and included 20 studies with a total of 831 patients. Indications for biopsy were: (1a) severe neurological disease of unknown etiology in adults (n = 7) and (1b) in children (n = 2); (2) suspected primary angiitis of the central nervous system (PACNS) (n = 3); (3) chronic meningitis of unknown cause (n = 3); (4) atypical dementia (n = 4); and (5) nonneoplastic disease (n = 1). Diagnostic success rates calculated for subgroups were 51.3% (34.5-68.1) for 1a, 53.8% (42.9-64.5) for 1b, 74.7% (64.0-84.1) for 2, 30.3% (17.2-45.4) for 3, and 60.8% (41.2-78.8) for 4. Clinical impact rates were 30.5% (13.6-50.6) for 1a (n = 6), 67.1% (42.8-87.3) for 1b (n = 2), 8.3% (2.3-20.0) for 3 (n = 1), and 14.2% (6.5-24.3) for 4 (n = 2). Lymphoma (n = 32) and Creutzfeldt-Jakob disease (n = 30) were the most common diagnoses on the final histopathology reports of positive brain biopsies in 1a. In 1b, encephalitis (n = 7), PACNS (n = 6), and demyelination (n = 6) were the most common. The odds ratio for achieving a diagnostic biopsy when there was a radiological target was 3.70 (P = .014, 95% confidence interval, 1.31-10.42).

CONCLUSION: Brain biopsy in cryptogenic neurological disease was associated with the highest diagnostic yield in patients with suspected PACNS. The greatest clinical impact was seen in children with cryptogenic neurological disease. The presence of a radiological target was associated with a higher diagnostic yield.

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Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy: a meta-analysis

Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy

Eur Spine J (2015) 24:31–39

This is a meta-analysis to compare the results between anterior cervical discectomy fusion (ACDF) and anterior cervical corpectomy fusion (ACCF) for the patients with multilevel cervical spondylotic myelopathy (MCSM).

Methods Systematic review and meta-analysis of cohort studies between ACDF with plate fixation and ACCF with plate fixation for the treatment of MCSM. An extensive search of literature was performed in PubMed, Mediline, Embase and the Cochrane library. The following outcome measures were extracted: JOA scores, fusion rate, cervical lordosis (C2–7), complications, blood loss and operation time. Data analysis was conducted with RevMan 5.0.

Results Four cohorts (six studies) involving 258 patients were included in this study. The pooled analysis showed that there was no significant difference in the postoperative JOA score [WMD = -0.14 (-1.37, 1.10), P = 0.83], fusion rate [OR = 0.84 (0.15, 4.86), P = 0.85] between two group. However, there was significant difference in the cervical lordosis [WMD = 3.38 (2.52, 4.23), P<0.00001], surgical complication rate and instrument related complication rate (P = 0.01, 0.005 respectively), blood loss [WMD = -52.53 (-73.53, -31.52), P<0.00001], and operation time [WMD = -14.10 (-20.27, -7.93), P<0.00001].

Conclusions As compared with ACCF with plate fixation, ACDF with plate fixation showed no significant differences in terms of postoperative JOA score, fusion rate, but better improved cervical lordosis, lower complication and smaller surgical trauma. As the limitations of small sample and short follow-up in this study, it still could not be identified whether ACDF with plate fixation is more effective and safer than ACCF with plate fixation.

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Proteomic analysis of cerebrospinal fluid: toward the identification of biomarkers for gliomas

Proteomics

Neurosurg Rev (2014) 37:367–380

Gliomas are the most common primary brain tumors in adults and, despite advances in the understandings of glioma pathogenesis in the genetic era, they are still ineradicable, justifying the need to develop more reliable diagnostic and prognostic biomarkers for this malignancy. Because changes in cerebrospinal fluid (CSF) are suggested to be capable of sensitively reflecting pathological processes, e.g., neoplastic conditions, in the central nervous system, CSF has been deemed a valuable source for potential biomarkers screening in this era of proteomics.

This systematic review focused on the proteomic analysis of glioma CSF that has been published to date and identified a total of 19 differentially expressed proteins. Further functional and protein-protein interaction assessments were performed by using Protein Analysis Through Evolutionary Relationships (PANTHER) website and Ingenuity Pathway Analysis (IPA) software, which revealed several important protein networks (e.g., IL- 6/STAT-3) and four novel focus proteins (IL-6, galanin (GAL), HSPA5, andWNT4) that might be involved in glioma pathogenesis.

The concentrations of these focus proteins were subsequently determined by enzyme-linked immunosorbent assay (ELISA) in an independent set of CSF and tumor cyst fluid (CF) samples. Specifically, glioblastoma (GBM) CF had significantly lower GAL, HSPA5, andWNT4 levels than CSF from different grades of glioma. In contrast, IL-6 level was significantly higher in GBM CF when compared with CSF and, among different CSF groups, was highest in GBM CSF.

Therefore, these candidate protein biomarkers, identified from both the literatures and in silico analysis, may have potentials in clinical diagnosis, prognosis evaluation, treatment response monitoring, and novel therapeutic targets identification for patients with glioma.

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Minimally invasive spine surgery for adult degenerative lumbar scoliosis

Minimally invasive spine surgery for adult degenerative lumbar scoliosis

Neurosurg Focus 36 (5):E7, 2014

Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery.

Methods. In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups.

Results. Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28).

Conclusions. The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.

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