Tag: Decision-making

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To fuse or not to fuse: surgical strategies for recurrent lumbar disc herniation from a 16-nation study

J Neurosurg Spine 43:681–692, 2025

This international survey examines variability in surgical management of recurrent lumbar disc herniation across 515 spine surgeons from 16 countries, comparing redo discectomy versus various fusion techniques for six clinical scenarios. Findings reveal substantial inter- and intranational differences, specialty-related tendencies, and consensus only for simple first recurrences without back pain.

The study identifies key decision drivers—lumbar pain with radiculopathy and inflammatory disc disease—highlights gaps in high-level evidence, and calls for standardized research, registries, and improved training to harmonize indications and reduce practice heterogeneity.

Significant International Variability: Surgical strategies for recurrent lumbar disc herniation (LDH) vary widely among spine surgeons internationally, especially beyond the first recurrence without low back pain or instability, where decisions are more homogeneous.

Decision-Making Factors: Key factors influencing the choice for fusion over redo discectomy include the presence of low back pain with radiculopathy, radiological evidence of inflammatory disc disease, and the occurrence of second recurrences.

Surgeon Specialty Impact: Orthopedic surgeons are significantly more likely to propose procedures involving implants (fusion) compared to neurosurgeons, regardless of other demographic factors.

Country-Specific Patterns: Countries with low variability (e.g., Portugal, China, UK, Germany) favor posterior lumbar interbody fusion (PLIF/TLIF) and redo discectomy, while countries with high variability (e.g., France, Tunisia, US, Brazil) show more diverse approaches, including anterior and combined procedures.

Limited Influence of Experience and Practice Type: Duration of practice, annual surgical volume, and type of institution (public vs. private) generally do not significantly affect procedure choice, except in some first recurrence cases where public practitioners favor redo discectomy.

Lack of High-Level Evidence: There is a lack of strong, consistent evidence or guidelines favoring one surgical approach over another for recurrent LDH, contributing to the observed variability.

Patient and Surgeon Preferences: Decision-making is influenced by patient preferences, surgeon familiarity with techniques, desire for low-morbidity procedures, and adherence to literature, though economic factors play a lesser role.

Call for Standardization and Research: The findings highlight the need for high-quality studies, improved training, and international collaboration to reduce variability and improve decision-making in recurrent LDH surgery.

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Neuropsychological deficits of vmPFC meningiomas

The cognitive and behavioral effects of meningioma lesions involving the ventromedial prefrontal cortex

J Neurosurg 124:1568–1577, 2016

Anterior skull base meningiomas are frequently associated with changes in personality and behavior. Although such meningiomas often damage the ventromedial prefrontal cortex (vmPFC), which is important for higher cognition, the cognitive and behavioral effects of these meningiomas remain poorly understood. Using detailed neuropsychological assessments in a large series of patients, this study examined the cognitive and behavioral effects of meningioma lesions involving the vmPFC.

Methods: The authors reviewed neuropsychology and lesion mapping records of 70 patients who underwent resection of meningiomas. The patients were drawn from the Neurological Patient Registry at the University of Iowa. Patients were sorted into 2 groups: those with lesions involving the vmPFC and those with lesions that did not involve the vmPFC. Neuropsychological data pertaining to a comprehensive array of cognitive and behavioral domains were available preoperatively in 20 patients and postoperatively in all 70 patients.

Results: No change occurred in basic cognitive functions (e.g., attention, perception, memory, construction and motor performance, language, or executive functions) from the preoperative to postoperative epochs for the vmPFC and non-vmPFC groups. There was a significant decline in the behavioral domain, specifically adaptive function, for both the vmPFC and non-vmPFC groups, and this decline was more pronounced for the vmPFC group. Additionally, postoperative data indicated that the vmPFC group had a specific deficit in value-based decision making, as evidenced by poor performance on the Iowa Gambling Task, compared with the non-vmPFC group. The vmPFC and non-vmPFC groups did not differ postoperatively on other cognitive measures, including intellect, memory, language, and perception.

Conclusions: Lesions of the vmPFC resulting from meningiomas are associated with specific deficits in adaptive function and value-based decision making. Meningioma patients showed a decline in adaptive function postoperatively, and this decline was especially notable in patients with vmPFC region meningiomas. Early detection and resection of meningiomas of the anterior skull base (involving the gyrus rectus) may prevent these deficits.

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Surgery in lumbar degenerative spondylolisthesis: indications, outcomes and complications. A systematic review

Lumbar spondylolisthesis

Eur Spine J (2014) 23:945–973

This systematic review summarises the literature on patient selection, decision-making, effectiveness and outcomes in the surgical treatment of lumbar degenerative spondylolisthesis (LDS). Introduction In daily practice, decision-making in the treatment of LDS is challenging. There is little consensus on either the precise indications or prognostic factors for any specific therapy (operative or non-operative).

Methods We searched for LDS trials published between 01.01.1990 and 16.11.2011 in Medline, Embase, Cochrane Library and Cinahl. Two independent reviewers selected studies according to the inclusion criteria. Data were then extracted by two of the authors. Quality assessment was performed using the Downs and Black list for the clinical trials/studies and AMSTAR for the reviews. Results Data synthesis: 21 papers met the inclusion criteria (2 studies comprising both a RCT and a concurrent observational analysis, 1 RCT, 6 prospective studies, 8 retrospective studies, 3 reviews, 1 review guideline). The quality of the clinical studies was on average ‘‘fair’’ [mean score 15.6 points (range 10–19) out of 24 points (Downs and Black)]. The quality of the reviews ranged from 1 to 7 out of 11 points with an average of 5 points (AMSTAR). The study outcomes could not be subject to meta-analysis due to heterogeneity of study design and variable measure used.

Conclusions Despite there being many articles describing and/or comparing different surgical options for LDS, there was insufficient evidence to draw conclusions concerning clear indications for specific types of surgical treatment, predictors of outcome or complication rates. There remains a need to establish a decision-making tool to facilitate daily clinical practice and to assure appropriate treatment for patients with LDS.

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