Tag: complications

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How Do Neurosurgeons Cope With Complications? Results of a Nationwide Survey

Neurosurgery 98:752–764, 2026

This study reports results of a nationwide survey assessing how neurosurgeons emotionally respond to surgical complications and which coping and defense mechanisms they use. It quantifies prevalence of patient harm, emotional impact, common adaptive and maladaptive behaviors, and associations with career effects such as limiting practice or contemplating leaving neurosurgery.

Findings show frequent use of intellectualization, humor, and affiliation alongside maladaptive behaviors that strongly predict career doubt and short-term practice changes, with junior surgeons reporting more coping strategies. The authors recommend institutional support, targeted interventions, and further longitudinal research to improve surgeon well-being and patient care.

Prevalence of serious complications Patient harm was commonly experienced: minor harm (87.3%), temporary harm (80.3%), long-term harm (79.6%), and patient death (58.4%).

Emotional impact Complications had a significant (55.6%) or profound (38.0%) immediate emotional impact, with long-term impact significant for 44.4% and profound for 12.7%.

Persistent preoccupation Respondents thought about complications weekly (41.5%) or daily (22.5%).

Common adaptive coping Frequent adaptive strategies included using errors as teaching opportunities (80.3%), speaking with a spouse/significant other (65.5%), exercise (61.9%), speaking with a mentor (51.4%), and speaking with friends (49.3%).

Common maladaptive coping Common maladaptive responses included sleep disturbances (52.8%), social withdrawal (38.0%), overeating (25.4%), procrastination (23.2%), and excessive alcohol consumption (11.3%).

Defense mechanisms used The most common defense mechanisms were intellectualization (68.3%) and humor (64.1), along with affiliation (61.2%) and altruism (53.5%).

Career/practice consequences tied to maladaptive coping Maladaptive coping was associated with higher odds of considering leaving the profession (OR 5.84) and limiting practice in the short term (OR 3.08).

Notable subgroup findings Junior neurosurgeons used more adaptive and maladaptive coping mechanisms than senior neurosurgeons, and academic neurosurgeons were more likely than private practitioners to question their clinical abilities (OR 2.68).

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Complications associated with anterior cervical spine surgery: A systematic review of literature

Brain and Spine 6 (2026) 105897

This systematic review examines complications following anterior cervical spine surgery, quantifying incidence rates across studies and identifying major risks such as dysphagia, adjacent segment disease, recurrent laryngeal nerve palsy, infection, pseudarthrosis, esophageal perforation, hematoma, and vertebral artery injury. It synthesizes data from 116 studies (1989–2024) and assesses study quality using the Newcastle–Ottawa Scale.

The review highlights key risk factors—multilevel procedures, revision surgery, OPLL, smoking, older age, and surgeon experience—and emphasizes the importance of preoperative planning, patient selection, standardized prospective monitoring, and timely management to minimize morbidity and guide informed consent and long-term surveillance.

Aim Quantify frequency, causes, and outcomes of complications associated with anterior cervical spine surgery.

Methods Systematic review following PRISMA; searched CINAHL Plus, MEDLINE, PubMed, Scopus, and EMBASE for English-language studies (1989–2024) in adults; quality assessed with the Newcastle Ottawa Scale.

Evidence base 326 records screened; 116 studies included; study quality ranged from 3/9 to 9/9 on NOS, with frequent weaknesses in external control selection and cohort comparability.

Most common complication (dysphagia) Reported incidence varied widely (2.3%–87.5%); overall rate across all included dysphagia studies was 13%, with higher pooled incidence in prospective vs retrospective cohorts (53.7% vs 12.7%).

Other key complications (ranges) Adjacent segment disease 0.4%–32%; recurrent laryngeal nerve palsy 0.1%–9%; infection 0.39%–8.5%; pseudarthrosis 0.25%–31%; esophageal perforation 0.1%–0.45%; vertebral artery injury 0.3%–7.7%; Horner’s syndrome 0.06%–0.45%; graft failure 2.7%–35.5%; CSF leak 0%–1%; postoperative hematoma 0.21%–7%; new/worsening neurological deficits 0.37%–3.3.

Risk factors (higher complication rates) Multilevel disease, revision surgery, and ossification of the posterior longitudinal ligament (OPLL) were associated with increased complications.

Volume–outcome effect Greater surgeon experience and higher case volume were consistently associated with lower complication rates.

Prevention emphasis Reducing complications depends on thorough preoperative planning, careful patient selection, and proper surgical technique.

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Surgery for mesial temporal pathology: a 26-year experience

J Neurosurg 143:738–747, 2025

Over 26 years, keyhole craniotomy via the inferior temporal gyrus for mesial temporal lobe surgery showed a low complication rate (5.3%), with only 0.3% permanent neurological deficits. Technique refinement and perioperative strategies minimized risks, supporting this approach as safe and effective for temporal lobe pathology.

A 26-year, single-surgeon study reviewed 717 mesial temporal lobe (MTL) surgeries using a keyhole inferior temporal gyrus (ITG) approach for epilepsy and other pathologies.

• Overall complication rate was low (5.3%), with only 0.3% of patients experiencing permanent neurological deficits and no perioperative deaths.

• Most common complications were hemorrhage (1.5%), postoperative seizure (1.3%), and cosmetic defects (0.6%).

• Neurological complications included transient cranial nerve deficits, visual field deficits, and speech difficulty, all rare.

• No significant correlation found between complications and age, sex, pathology type, operative time, or blood loss.

• Technical strategies such as meticulous closure, careful muscle reapproximation, and limiting brain retraction reduced complications over time.

• The ITG keyhole approach provided safe, effective, and cosmetically favorable access to the MTL, with complication rates improving as technique and teaching matured.

• Long-term follow-up (97% at 36 months) confirmed sustained safety and efficacy of this approach.

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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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Safety and therapeutic impact of stereotactic biopsy in very elderly patients with brain tumors

J Neurosurg 143:194–203, 2025

Stereotactic brain biopsy in patients aged ≥80 is safe, with high diagnostic yield (96.2%) and low persistent neurological deficit (1.9%). Prebiopsy Karnofsky Performance Status ≥70% predicts full adjuvant therapy and longer survival. Biopsy findings frequently alter management, supporting its use in very elderly brain tumor patients.

• Stereotactic brain biopsy in patients aged ≥80 years is safe and has a high diagnostic yield (96.2%).

• Symptomatic complication rate was 6.2%, with persistent neurological deficit in 1.9% and a procedure-related mortality of 0.5%.

• The biopsy changed the suspected diagnosis in 11.1% of cases, influencing patient management.

• 80.7% of patients received adjuvant treatment after biopsy; 19.3% received palliative care.

• A Karnofsky Performance Status (KPS) score ≥70% was the only significant predictor for receiving full adjuvant therapy and longer overall survival (OS).

• Median OS after biopsy was 5.6 months; longer in patients with PCNSL or methylated MGMT promoter in glioma.

• No significant increase in complications was seen with deep-seated tumors, anticoagulant use, or advanced age (≥85 or ≥90 years).

• The study supports considering biopsy for very elderly patients when technically feasible and patient condition is good.

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The Rate and Risk Factors of Deep Brain Stimulation–Associated Complications

Operative Neurosurgery 28:519–527, 2025

The study investigates complications associated with deep brain stimulation (DBS) surgery, analyzing patient demographics, surgical techniques, and outcomes. It identifies factors influencing complications such as pneumocephalus, infection, and hemorrhage, aiming to improve patient selection and surgical strategies for better outcomes.

• Deep Brain Stimulation (DBS) is a recognized neurosurgical procedure for various neurological disorders, considered safe but not without complications. The study investigates these complications and their association with patient characteristics and surgical techniques.

• The study analyzed 481 patients who underwent DBS lead implantation between January 2012 and January 2020, with a total of 859 leads implanted.

• Common complications included pneumocephalus, edema, altered mental state, and infection. General anesthesia, hypertension, heart disease, and depression were linked to longer postoperative stays.

• High BMI was associated with increased rates of surgery-related infections and lead revision/explantation.

• Intraoperative mean arterial pressure and anesthesia type were significant predictors of postoperative pneumocephalus.

• The study found that certain comorbidities, such as hypertension, heart disease, and depression, were associated with longer hospital stays.

• Older patients were less likely to require lead revision/explantation, while those with high BMI were at higher risk.

• Infection prevention techniques, like vancomycin powder, were effective, with infection rates at the lower end of the reported range.

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Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial

Neurosurgery 96:131–141, 2025

Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW.

METHODS: In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon’s discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. RESULTS: A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively.

CONCLUSION: Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

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Optimal Timing of Cranioplasty After Decompressive Craniectomy: Timing or Collapse Ratio

Operative Neurosurgery 27:715–723, 2024

Although cranioplasty (CP) is a relatively straightforward surgical procedure, it is associated with a high complication rate. The optimal timing for this surgery remains undetermined. This study aimed to identify the most suitable timing for CP to minimize postoperative complications.

METHODS: We conducted a retrospective analysis of all CP cases performed in our department from August 2015 to March 2022. Data were gathered through case statistics and categorized based on the occurrence of complications. The collapse ratio was determined using 3-dimensional Slicer software.

RESULTS: In our retrospective study of 266 patients, 51 experienced postoperative complications, including hydrocephalus, epidural effusion, subdural hematoma, epilepsy, and subcutaneous infection. Logistic regression analysis identified independent predictors of postcranioplasty complications, and a nomogram was developed. The predictive value of the logistic regression model, collapse ratio, and decompression craniotomy-CP operation interval for post–skull repair complications was assessed using receiver operating characteristic curve analysis. No significant differences were observed in postoperative complications and decompression craniotomy-CP intervals between the groups (P = .07, P > .05). However, significant differences were noted in postoperative collapse ratios and CP complications between the groups (P = .023, P < .05). Logistic regression revealed that the collapse ratio (odds ratio = 1.486; 95% CI: 1.001-2.008; P = .01) and CP operation time (odds ratio = 1.017; 95% CI: 1.008-1.025, P < .001) were independent risk factors for postoperative complications. Receiver operating characteristic curve analysis indicated that the collapse ratio could predict CP postoperative complications, with a cutoff value of 0.274, an area under the curve of 0.621, a sensitivity of 62.75%, and a specificity of 63.26%.

CONCLUSION: The post–skull repair collapse ratio is a significant predictor of postoperative complications. It is advisable to base the timing of surgery on the extent of brain tissue collapse, rather than solely on the duration between cranial decompression and CP.

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Complication rates after autologous cranioplasty following decompressive craniectomy

Acta Neurochirurgica (2024) 166:380

The reimplantation of autologous bone grafts after decompressive craniectomy (DC) is still up for debate. The objective of this study was to analyze the surgical revision rate for autologous cranioplasties in our center, aiming to identify predictors for procedure-related-complications.

Methods A retrospective single-center study was conducted for adult patients who underwent autologous cranioplasty after DC. The primary endpoint was the complication rate in terms of surgical revision and removal of the bone graft: infection, new onset seizures, dislocation, haemorrhage, osteolysis, wound dehiscence and cerebrospinal fluid (CSF) fistula. Demographic data, medical records, surgical reports and imaging studies were analysed and risk factors for complications were evaluated.

Results 169 consecutive patients were included. The median interval between DC and cranioplasty was 84 days. Mean age was 51 ± 12.4 years. 26 patients (15.3%) had revision surgery for following reasons. n = 9 implant dislocations (5.3%), n = 7 osteolysis (3.6%), n = 6 infections (3.6%), n = 5 had re-bleedings (3%), n = 5 wound dehiscences (3%), and n = 2 CSF fistulas (1.2%). 18 patients developed new seizures (10.7%). Bi- and multivariate analysis revealed three independent risk factors, simultaneous ventriculo-peritoneal (VP) shunting increased the risk for material dislocation (p < 0.001); large bone grafts (> 193.5 cm2 ) increased the risk for osteolysis (p = 0.001) and bifrontal cranioplasties were associated with higher risk for infections (p = 0.04).

Conclusion The complication rates in our study were comparable to previously reported data for autologous or artificial cranioplasties. As osteolysis was correlated to larger bone grafts, a synthetic alternative should be considered in selected cases.

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Accurate placement of thoracolumbar pedicle screws using a handheld iOS-based navigation device

The Spine Journal 24 (2024) 1671−1677

Accurate pedicle screw placement is a challenge with reported misplacement rates of 10% and higher. A handheld navigation device (HND) may provide accuracy equal to CT-based navigation (CT-Nav) but without the cost and complexity.

OBJECTIVE: To study the accuracy of a handheld navigation device for pedicle screw placement. STUDY DESIGN: This prospective cross-sectional study with consistently applied reference standard enrolled 20 patients undergoing 92 pedicle screw placements.

PATIENTS: Patients who underwent pedicle screw placement between May 2022 and September 2022.

OUTCOME MEASURES: Pedicle screw placement accuracy per Gertzbein−Robbins.

METHODS: Once the screw pilot hole was established, the proposed trajectory of the HND was compared with that proposed by CT-Nav. Postoperatively, screw accuracy was graded according to Gertzbein−Robbins by a blinded radiologist based on CT scans. Accuracy was compared between the two systems and published control for fluoroscopy assisted and CT-Nav placement using Bayesian posterior distribution.

RESULTS: The trajectory proposed by the HND and CT-Nav were in agreement in 98.9% (95% Exact CI; 94.09%−99.97%). The HND accuracy was 98.9% with 91 screws rated “A” and 1 rated “C”. Noninferiority to fluoroscopic placement was achieved because the one-sided normalapproximation 95% CI Lower Bound (LB) of 95.3% is greater than the Performance Goal (PG) of 83.4%. Posthoc analysis demonstrated that the probability of superiority of the HND relative to the historical accuracy rate of 91.5% for fluoroscopy assisted procedures is >0.999 and that the HND’s accuracy rate is within 4.5% of CT-Nav of 95.5% is >0.999. No adverse events or intra-operative complications associated with HND were observed. There was 1 (1.1%) intra-operative repositioning and no reoperations for any reason.

CONCLUSIONS: The accuracy rate of the HND was 98.9%, and the proposed trajectory matched with CT-Nav in 98.9% of the time. This is superior to the historical published accuracy rate for fluoroscopy-assisted procedures and equivalent to the historical published accuracy rate for CT-Nav.

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A retrospective analysis of perioperative complications of lateral approach lumbar interbody fusion in patients with prior abdominal surgery or a history of colonic inflammatory disease

The Spine Journal 24 (2024) 1451−1458

Lateral approaches for lumbar interbody fusion (LIF) allow for access to the lumbar spine and disc space by passing through a retroperitoneal corridor either preor trans-psoas. A contraindication for this approach is the presence of retroperitoneal scarring that may occur from prior surgical intervention in the retroperitoneal space or from inflammatory conditions with fibrotic changes and pose challenges for the mobilization and visualization needed in this approach. However, there is a paucity of evidence on the prevalence of surgical complications following lateral fusion surgery in patients with a history of abdominal surgery.

PURPOSE: The primary aim of this study is to describe the association between surgical complications following lateral interbody fusion surgery and prior abdominal surgical.

STUDY DESIGN: Retrospective study.

PATIENT SAMPLE: Patients over the age of 18 who underwent lateral lumbar interbody fusion at a large, tertiary care center between 2011 and 2019 were included in the study.

OUTCOME MEASURES: The primary outcome included medical, surgical, and thigh-related complications either in the intraoperative or 90-day postoperative periods. Additional outcome metrics included readmission rates, length of stay, and operative duration.

METHODS: The electronic health records of 250 patients were reviewed for demographic information, surgical data, complications, and readmission following surgery. The association of patient and surgical factors to complication rate was analyzed using multivariable logistic regression. Statistical analysis was performed using R statistical software (R, Vienna, Austria).

RESULTS: Of 250 lateral interbody fusion patients, 62.8% had a prior abdominal surgery and 13.8% had a history of colonic disease. The most common perioperative complication was transient thigh or groin pain/sensory changes (n=62, 24.8%). A multivariable logistic regression considering prior abdominal surgery, age, BMI, history of colonic disease, multilevel surgery, and the approach relative to psoas found no significant association between surgical complication rates and colonic disease (OR 0.40, 95% CI 0.02−2.22) or a history of prior abdominal surgeries (OR 0.56, 95% CI 0.20−1.55). Further, the invasiveness of prior abdominal surgeries showed no association with overall spine complication rate, lateral-specific complications, or readmission rates (p>.05).

CONCLUSION: Though retroperitoneal scarring is an important consideration for lateral approaches to the lumbar spine, this study found no association between lateral lumbar approach complication rates and prior abdominal surgery. Further study is needed to determine the impact of inflammatory colonic disease on lateral approach spine surgery.

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Presentation and Management of Cerebral Venous Sinus Thrombosis After Supratentorial Craniotomy

Neurosurgery 95:34–45, 2024

Cerebral venous sinus thrombosis (CVST) after supratentorial craniotomy is a poorly studied complication, for which there are no management guidelines. This study assessed the incidence, associated risk factors, and management of postoperative CVST after awake craniotomy.

METHODS: This is an observational, retrospective, monocentric analysis of patients who underwent a supratentorial awake craniotomy. Postoperative CVST was defined as a flow defect on the postoperative contrast-enhanced 3D T1weighted sequence and/or as a T2* hypointensity within the sinus.

RESULTS: In 401 supratentorial awake craniotomies (87.3% of diffuse glioma), the incidence of postoperative CVST was 4.0% (95% CI 2.5-6.4): 14/16 thromboses located in the superior sagittal sinus and 12/16 located in the transverse sinus. A venous sinus was exposed during craniotomy in 45.4% of cases, and no intraoperative injury to a cerebral venous sinus was reported. All thromboses were asymptomatic, and only two cases were diagnosed at the time of the first postoperative imaging (0.5%). Postoperative complications, early postoperative Karnofsky Performance Status score, and duration of hospital stay did not significantly differ between patients with and without postoperative CVST. Adjusted independent risk factors of postoperative CVST were female sex (adjusted Odds Ratio 4.00, 95% CI 1.24-12.91, P = .021) and a lesion ≤1 cm to a venous sinus (adjusted Odds Ratio 10.58, 95% CI 2.93-38.20, P < .001). All patients received standard prophylactic-dose anticoagulant therapy, and none received treatment-dose anticoagulant therapy. No thrombosis-related adverse event was reported. All thromboses presented spontaneous sinus recanalization radiologically at a mean of 89 ± 41 days (range, 7-171).

CONCLUSION: CVST after supratentorial awake craniotomy is a rare event with satisfactory clinical outcomes and spontaneous sinus recanalization under conservative management without treatment-dose anticoagulant therapy. These findings are comforting to neurosurgeons confronted with postoperative MRI reports suggesting CVST.

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Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms—A Global Multicenter Investigation of Perioperative Outcomes

Neurosurgery 94:1218–1226, 2024

Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms.

METHODS: Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics.

RESULTS: Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers.

CONCLUSION: Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

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Surgical Outcome of Patients With Supratentorial Meningiomas Aged 80 Years or Older

Neurosurgery 94:399–412, 2024

Demographic changes will lead to an increase in old patients, a population with significant risk of postoperative morbidity and mortality, requiring neurosurgery for meningiomas. This multicenter study aims to report neurofunctional status after resection of patients with supratentorial meningioma aged 80 years or older, to identify factors associated with outcome, and to validate a previously proposed decision support tool.

METHODS: Neurofunctional status was assessed by the Karnofsky Performance Scale (KPS). Patients were categorized in poor (KPS ≤40), intermediate (KPS 50-70), and good (KPS ≥80) preoperative subgroups. Volumetric analyses of tumor and peritumoral brain edema (PTBE) were performed; volumes were scored as small (<10 cm3 ), medium (10-50 cm3 ), and large (>50 cm3 ).

RESULTS: The study population consisted of 262 patients, and the median age at surgery was 83.0 years. The median preoperative KPS was 70; 117 (44.7%) patients were allotted to the good, 113 (43.1%) to the intermediate, and 32 (12.2%) to the poor subgroup. The median tumor and PTBE volumes were 30.2 cm 3 and 27.3 cm3 ; large PTBE volume correlated with poor preoperative KPS status (P = .008). The 90-day and 1-year mortality rates were 9.0% and 13.2%, respectively. Within the first postoperative year, 101 (38.5%) patients improved, 87 (33.2%) were unchanged, and 74 (28.2%) were functionally worse (including deaths). Each year increase of age associated with 44% (23%-70%) increased risk of 90-day and 1-year mortality. In total, 111 (42.4%) patients suffered from surgery-associated complications. Maximum tumor diameter ≥5 cm (odds ratio 1.87 [1.12-3.13]) and large tumor volume (odds ratio 2.35 [1.01-5.50]) associated with increased risk of complications. Among patients with poor preoperative status and large PTBE, most (58.3%) benefited from surgery.

CONCLUSION: Patients with poor preoperative neurofunctional status and large PTBE most often showed postoperative improvements. The decision support tool may be of help in identifying cases that most likely benefit from surgery.

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Preemptive strategies and lessons learned from complications encountered with microvascular decompression for hemifacial spasm

J Neurosurg 140:248–259, 2024

OBJECTIVE Microvascular decompression (MVD) is the only curative treatment modality for hemifacial spasm (HFS). Although generally considered to be safe, this surgical procedure is surrounded by many risks and possible complications. The authors present the spectrum of complications that they met in their case series, the possible causes, and the strategies recommended to minimize them.

METHODS The authors reviewed a prospectively maintained database for MVDs performed from 2005 until 2021 and extracted relevant data including patient demographics, offending vessel(s), operative technique, outcome, and different complications. Descriptive statistics with uni- and multivariable analyses for the factors that may influence the seventh, eighth, and lower cranial nerves were performed.

RESULTS Data from 420 patients were obtained. Three hundred seventeen of 344 patients (92.2%) with a minimum follow-up of 12 months had a favorable outcome. The mean follow-up (standard deviation) was 51.3 ± 38.7 months. Immediate complications reached 18.8% (79/420). Complications persisted in only 7.14% of patients (30/420) including persistent hearing deficits (5.95%) and residual facial palsy (0.95%). Temporary complications included CSF leakage (3.10%), lower cranial nerve deficits (3.57%), meningitis (0.71%), and brainstem ischemia (0.24%). One patient died because of herpes encephalitis. Statistical analyses showed that the immediate postoperative disappearance of spasms and male gender are correlated with postoperative facial palsy, whereas combined vessel compressions involving the vertebral artery (VA) and anterior inferior cerebellar artery can predict postoperative hearing deterioration. VA compressions could predict postoperative lower cranial nerve deficits.

CONCLUSIONS MVD is safe and effective for treating HFS with a low rate of permanent morbidity. Proper patient positioning, sharp arachnoid dissection, and endoscopic visualization under facial and auditory neurophysiological monitoring are the key points to minimize the rate of complications in MVD for HFS.

 

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International Tuberculum Sellae Meningioma Study: Surgical Outcomes and Management Trends

Neurosurgery 93:1259–1270, 2023

Tuberculum sellae meningiomas (TSMs) can be resected through transcranial (TCA) or expanded endonasal approach (EEA). The objective of this study was to report TSM management trends and outcomes in a large multicenter cohort.

METHODS: This is a 40-site retrospective study using standard statistical methods.

RESULTS: In 947 cases, TCA was used 66.4% and EEA 33.6%. The median maximum diameter was 2.5 cm for TCA and 2.1 cm for EEA (P < .0001). The median follow-up was 26 months. Gross total resection (GTR) was achieved in 70.2% and did not differ between EEA and TCA (P = .5395). Vision was the same or better in 87.5%. Vision improved in 73.0% of EEA patients with preoperative visual deficits compared with 57.1% of TCA patients (P < .0001). On multivariate analysis, a TCA (odds ratio [OR] 1.78, P = .0258) was associated with vision worsening, while GTR was protective (OR 0.37, P < .0001). GTR decreased with increased diameter (OR: 0.80 per cm, P = .0036) and preoperative visual deficits (OR 0.56, P = .0075). Mortality was 0.5%. Complications occurred in 23.9%. New unilateral or bilateral blindness occurred in 3.3% and 0.4%, respectively. The cerebrospinal fluid leak rate was 17.3% for EEA and 2.2% for TCA (OR 9.1, P < .0001). The recurrence rate was 10.9% (n= 103). Longer follow-up (OR 1.01 per month, P < .0001), World Health Organization II/III (OR 2.20, P = .0262), and GTR (OR: 0.33, P < .0001) were associated with recurrence. The recurrence rate after GTR was lower after EEA compared with TCA (OR 0.33, P = .0027).

CONCLUSION: EEA for appropriately selected TSM may lead to better visual outcomes and decreased recurrence rates after GTR, but cerebrospinal fluid leak rates are high, and longer follow-up is needed. Tumors were smaller in the EEA group, and follow-up was shorter, reflecting selection, and observation bias. Nevertheless, EEA may be superior to TCA for appropriately selected TSM.

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Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study

Neurosurgery 93:1106–1111, 2023

The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date.

METHODS: A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay.

RESULTS: A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms—8.2%, new lower extremity weakness—5.8%, wound infection—1.4%, cage subsidence—0.8%, psoas hematoma—0.5%, small bowel obstruction and ischemia—0.3%, and 90-day readmission—1.9%.

CONCLUSION: In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

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Complications associated with single-position prone lateral lumbar interbody fusion

J Neurosurg Spine 39:380–386, 2023

Lateral lumbar interbody fusion (LLIF) is a workhorse surgical approach for lumbar arthrodesis. There is growing interest in techniques for performing single-position surgery in which LLIF and pedicle screw fixation are performed with the patient in the prone position. Most studies of prone LLIF are of poor quality and without long-term followup; therefore, the complication profile related to this novel approach is not well known. The objective of this study was to perform a systematic review and pooled analysis to understand the safety profile of prone LLIF.

METHODS A systematic review of the literature and a pooled analysis were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies reporting prone LLIF were assessed for inclusion. Studies not reporting complication rates were excluded.

RESULTS Ten studies meeting the inclusion criteria were analyzed. Overall, 286 patients were treated with prone LLIF across these studies, and a mean (SD) of 1.3 (0.2) levels per patient were treated. The 18 intraoperative complications reported included cage subsidence (3.8% [3/78]), anterior longitudinal ligament rupture (2.3% [5/215]), cage repositioning (2.1% [2/95]), segmental artery injury (2.0% [5/244]), aborted prone interbody placement (0.8% [2/244]), and durotomy (0.6% [1/156]). No major vascular or peritoneal injuries were reported. Sixty-eight postoperative complications occurred, including hip flexor weakness (17.8% [21/118]), thigh and groin sensory symptoms (13.3% [31/233]), revision surgery (3.8% [3/78]), wound infection (1.9% [3/156]), psoas hematoma (1.3% [2/156]), and motor neural injury (1.2% [2/166]).

CONCLUSIONS Single-position LLIF in the prone position appears to be a safe surgical approach with a low complication profile. Longer-term follow-up and prospective studies are needed to better characterize the long-term complication rates related to this approach.

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Operative treatment outcomes for adult cervical deformity: a prospective multicenter assessment with mean 3-year follow-up

J Neurosurg Spine 37:855–864, 2022

Adult cervical deformity (ACD) has high complication rates due to surgical complexity and patient frailty. Very few studies have focused on longer-term outcomes of operative ACD treatment. The objective of this study was to assess minimum 2-year outcomes and complications of ACD surgery.

METHODS A multicenter, prospective observational study was performed at 13 centers across the United States to evaluate surgical outcomes for ACD. Demographics, complications, radiographic parameters, and patient-reported outcome measures (PROMs; Neck Disability Index, modified Japanese Orthopaedic Association, EuroQol-5D [EQ-5D], and numeric rating scale [NRS] for neck and back pain) were evaluated, and analyses focused on patients with ≥ 2-year follow-up.

RESULTS Of 169 patients with ACD who were eligible for the study, 102 (60.4%) had a minimum 2-year follow-up (mean 3.4 years, range 2–8.1 years). The mean age at surgery was 62 years (SD 11 years). Surgical approaches included anterior-only (22.8%), posterior-only (39.6%), and combined (37.6%). PROMs significantly improved from baseline to last follow-up, including Neck Disability Index (from 47.3 to 33.0) and modified Japanese Orthopaedic Association score (from 12.0 to 12.8; for patients with baseline score ≤ 14), neck pain NRS (from 6.8 to 3.8), back pain NRS (from 5.5 to 4.8), EQ-5D score (from 0.74 to 0.78), and EQ-5D visual analog scale score (from 59.5 to 66.6) (all p ≤ 0.04). More than half of the patients (n = 58, 56.9%) had at least one complication, with the most common complications including dysphagia, distal junctional kyphosis, instrumentation failure, and cardiopulmonary events. The patients who did not achieve 2-year follow-up (n = 67) were similar to study patients based on baseline demographics, comorbidities, and PROMs. Over the course of follow-up, 23 of the total 169 enrolled patients were reported to have died. Notably, these represent all-cause mortalities during the course of follow-up.

CONCLUSIONS This multicenter, prospective analysis demonstrates that operative treatment for ACD provides significant improvement of health-related quality of life at a mean 3.4-year follow-up, despite high complication rates and a high rate of all-cause mortality that is reflective of the overall frailty of this patient population. To the authors’ knowledge, this study represents the largest and most comprehensive prospective effort to date designed to assess the intermediate-term outcomes and complications of operative treatment for ACD.

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Microsurgical sealing for symptomatic sacral Tarlov cysts: a series of 265 cases

J Neurosurg Spine 37:905–913, 2022

Tarlov cysts (TCs) are a common cystic entity in the sacral canal, with a reported prevalence between 1.5% and 13.2%; 10%–20% of patients are symptomatic and need appropriate clinical intervention. However, the choice of treatment remains controversial. The goal of this study was to describe a new microsurgical sealing technique for symptomatic sacral TCs (SSTCs) as well as its long-term outcomes.

METHODS Microsurgical sealing was performed using a short incision, leakage coverage with a piece of autologous fat, and cyst sealing with fibrin glue. Postoperative data were collected at three stages: discharge, 1-year follow-up, and a follow-up of 3 years or more. According to the improvement in neurological deficits and degree of pain relief, outcomes were divided into four levels: excellent, good, unchanged, and deteriorated.

RESULTS A total of 265 patients with SSTCs were treated with microsurgical sealing from January 2003 to December 2020. The mean follow-up was 44.69 months. The percentages of patients who benefited from the operation (excellent and good) at the three stages were 87.55%, 84.89%, and 80.73%, respectively, while those who received no benefit (unchanged and deteriorated) were 12.45%, 15.11%, and 19.27%, respectively. Of the patients with postoperative MRI, the cysts were reduced in size or disappeared in 209 patients (94.14%). CSF leakage from the wound was observed in 15 patients, and 4 patients experienced an infection at the incision. There were no cases of new-onset nerve injury or aseptic meningitis after the operation.

CONCLUSIONS SSTC patients undergoing microsurgical sealing had persistently high rates of symptom relief and few postoperative complications. Microsurgical sealing is an effective, simple, and low-risk method for treating SSTCs.

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