Tag: Risk factors

Posted on

Risk Factors and Reoperation Rate in Revision Lumbar Disc Herniation Surgery: A Systematic Review and Meta-Analysis of 1,031,348 Patients

Global Spine Journal 2026, Vol. 16(3) 1633-1647

This systematic review and meta-analysis examines reoperation rates and associated risk factors following primary lumbar disc herniation surgery across 25 studies totaling 1,031,348 patients. Pooled reoperation rate was 8.5% overall (adjusted to 10.3% for publication bias), with rates varying by follow-up: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% beyond 5 years.

Key risk factors identified include smoking, older age, diabetes, and large annular defects, while sex was not significant. The review highlights heterogeneity across study designs and follow-up durations, recommends careful patient selection, extended conservative management or closer surveillance for high-risk patients, and calls for trials comparing revision techniques.

Objective Estimate the reoperation rate after lumbar disc herniation surgery and identify associated risk factors.

Evidence base 25 studies (including observational studies and 3 RCTs) totaling 1,031,348 patients were included.

Overall reoperation rate Pooled reoperation rate was 8.5% (95% CI 6.2%–11.6%); after trim-and-fill adjustment for publication bias it was 10.3% (95% CI 7.6%–14.0%).

Follow-up pattern Reoperation rates differed by follow-up duration: 4% at ≤1 year, 11.1% at 1–5 years, and 8.8% at >5 years (significant subgroup differences).

Smoking risk Smoking was associated with higher odds of reoperation (OR 1.39, 95% CI 1.09–1.78).

Age risk Older age was associated with higher odds of reoperation (OR 1.52, 95% CI 1.25–1.85).

Annular defect risk Larger annular defect size was associated with higher odds of reoperation (OR 2.19, 95% CI 1.07–4.48).

Other factors Diabetes and certain surgical techniques were linked to higher reoperation risk in individual studies; sex was not a significant predictor (OR 1.22, 95% CI 0.96–1.55).

Posted on

Predicting chronic subdural hematoma risk in elderly patients with mild traumatic brain injury

Acta Neurochirurgica (2026) 168:40

This study develops and validates a concise bedside risk score to predict chronic subdural hematoma (CSDH) within 2–12 weeks after mild traumatic brain injury in patients aged 65+. Using a large retrospective cohort (7,246 events) and multivariable modeling, pathological CT at presentation, male sex, older age, and renal failure emerged as key predictors.

The score-based model (including anticoagulant use by expert choice) achieved AUROC 0.76 and 86% sensitivity at the chosen threshold, classifying ~61% as high-risk. Authors propose this tool to guide targeted surveillance and earlier intervention, while noting limitations from retrospective data and need for external validation.

Pathological CT Findings: Pathological findings on initial head CT after mild traumatic brain injury (TBI) are the strongest predictor for developing chronic subdural hematoma (CSDH) within 2–12 weeks in elderly patients.

Key Risk Factors: Older age, male sex, and renal failure are also significant independent predictors for CSDH following mild TBI.

Anticoagulant Use: Chronic use of anticoagulant medications showed a trend toward increased risk but was not statistically significant in this cohort; antiplatelet use was not associated with increased risk.

Prediction Model: A simple score-based risk model was developed, incorporating pathological CT (14 points), male sex (4), renal failure (4), anticoagulant use (4), and age (1 point per 5 years over 65), with a threshold of 5 points or higher identifying high-risk patients.

Model Performance: The risk model achieved an area under the ROC curve (AUROC) of 0.76 and a sensitivity of 86% for detecting CSDH, but the positive predictive value was low (1.6%) due to the rare occurrence of the outcome.

Clinical Implications: Early identification of high-risk patients may enable targeted surveillance, timely CT scanning, and consideration of non-surgical management options such as corticosteroids or middle meningeal artery embolization.

Population Impact: The incidence of CSDH is rising globally due to population aging and increased use of antithrombotic agents, with elderly adults being particularly at risk.

Study Scope: The findings support the use of bedside risk stratification in the emergency department for elderly patients with mild TBI, but further research is needed before widespread clinical implementation.

Posted on

Development and internal validation of a risk score for subsidence of expandable spacers in transforaminal lumbar interbody fusion (TLIF) surgery

Brain and Spine 5 (2025) 104322

This study developed and internally validated the Expandable TLIF Subsidence Index (ETSI) to predict risk of cage subsidence after TLIF surgery with expandable spacers. Key risk factors include high ASA score, non-degenerative indication, lower lumbar levels, small cage size, and posterior cage position.

• A risk score (Expandable TLIF Subsidence Index, ETSI) was developed to predict cage subsidence (CS) after transforaminal lumbar interbody fusion (TLIF) using expandable spacers.

• The study analyzed 388 patients (482 levels), finding a 31.7% CS rate at 3 months.

• Independent risk factors for CS included high ASA score, non-degenerative surgical indication, lower lumbar level, small cage size, and posterior cage position.

• The ETSI score ranges from -2 to 6; higher scores indicate higher CS risk (each point increases CS odds by about 2x).

• Modifiable risk factors (cage size and position) can reduce CS risk if addressed during surgery.

• Higher ETSI scores are also associated with increased risk of non-union/pseudarthrosis.

• The ETSI demonstrated moderate predictive performance (AUROC ≈ 0.68).

• The score may aid surgical planning and should be externally validated in future studies.

Posted on

Development and internal validation of a risk score for subsidence of expandable spacers in transforaminal lumbar interbody fusion (TLIF) surgery

Brain and Spine 5 (2025) 104322

This study developed and validated the Expandable TLIF Subsidence Index (ETSI) to predict risk of cage subsidence after TLIF surgery with expandable spacers. Key risk factors include high ASA score, non-degenerative indications, lower lumbar level, small cage size, and posterior cage position. Some risk factors are modifiable.

• A risk score (ETSI) was developed to predict cage subsidence (CS) after TLIF surgery using expandable spacers.

• Independent risk factors for CS include high ASA score, non-degenerative surgical indication, lower lumbar level, small cage size, and posterior cage position.

• ETSI ranges from -2 to 6 points and shows a moderate ability to classify CS risk (AUROC ≈ 0.68).

• Modifiable risk factors (cage size and position) can reduce CS risk if optimized by the surgeon.

• Higher ETSI scores are associated with increased risk of non-union/pseudarthrosis at 3 and 12 months.

• Anterior placement of the cage lowers subsidence risk, while posterior placement increases it.

• The study included 388 patients with a 3-month CS rate of 31.7%.

• The ETSI is the first comprehensive scoring system for CS risk with expandable TLIF cages.

Posted on

Factors affecting outcomes following burr hole drainage of chronic subdural hematoma

J Neurosurg 142:1606–1615, 2025

This large single-center retrospective study of 1226 patients found that preoperative factors—age under 80, independence, higher GCS motor score, fewer medications, and lower ASA grade—predict better outcomes after burr hole drainage for chronic subdural hematoma. Surgical drain use and shorter bed rest improved discharge outcomes, but recurrence was not linked to modifiable factors.

• Chronic subdural hematoma (CSDH) is a common neurosurgical condition, especially in elderly patients, and burr hole craniostomy (BHC) is the main surgical treatment.

• This large single-center retrospective study (n=1226) analyzed predictors of outcomes, complications, recurrence, and hospital length of stay (LOS) after BHC for CSDH.

• Favorable short-term outcomes were associated with age <80, preadmission independence, preoperative GCS motor score of 6, fewer than 5 regular medications, and ASA grades I–II.

• Use of a subdural drain and shorter postoperative bed rest (1 day vs 2 days) were linked to better outcomes and higher odds of discharge home.

• No modifiable or nonmodifiable factors, including surgical technique, were significantly associated with CSDH recurrence.

• Polypharmacy (>4 medications) and older age were associated with higher risk of complications and longer hospital LOS.

• Antithrombotic use was not significantly associated with clinical outcomes, recurrence, complications, or LOS.

• Long-term survival was mainly influenced by baseline patient factors (age, independence, GCS-M, ASA grade), not surgical variables.

Posted on

Hook Fixation at Uppermost Instrumented Vertebra +1 Reduced Proximal Junctional Failure in Adult Patients With Spinal Deformity Having Achieved Optimal Deformity Correction by Sagittal Age-Adjusted Score

Neurosurgery 96:308–317, 2025

• Study Focus: The study investigates risk factors for proximal junctional failure (PJF) in elderly patients undergoing spinal deformity surgery despite achieving optimal sagittal correction.

• Methodology: Retrospective analysis of patients aged 60+ who underwent ≥5-level spinal fusion, focusing on those achieving optimal sagittal correction relative to the sagittal age-adjusted score (SAAS).

• Key Findings: High body mass index (BMI), high lumbar distribution index (LDI), and absence of hook fixation at UIV + 1 are significant risk factors for PJF.

• Statistical Analysis: Multivariate analysis confirmed these risk factors, with BMI and LDI showing significant predictive power for PJF development.

• Clinical Implications: Managing BMI, LDI, and ensuring hook fixation at UIV + 1 could reduce PJF rates, even with optimal sagittal correction.

• Limitations: The study’s generalizability is limited by the predominance of patients with UIV in the lower thoracic spine and inconsistent use of preventive methods.

• Conclusion: Proper management of identified risk factors, along with optimal sagittal correction, may further decrease PJF incidence.

Posted on

Could indirect decompression occur for cord compression by the ligamentum flavum with anterior cervical discectomy and fusion?

J Neurosurg Spine 42:100–109, 2025

Cord compression by the ligamentum flavum (CCLF) has been reported to adversely affect the clinical outcomes of anterior cervical discectomy and fusion (ACDF). While indirect decompression does occur for foraminal stenosis with ACDF, whether ACDF could improve CCLF with the distraction of disc space remains unclear. This study aimed to identify 1) whether indirect decompression occurs for CCLF with ACDF, and 2) risk factors that hinder the improvement of CCLF.

METHODS This retrospective cohort study included 119 patients who underwent ACDF for the treatment of cervical myelopathy and CCLF was detected on preoperative MRI. Patients who demonstrated improvement in CCLF grade after ACDF were included in the improved group, while those who did not show improvement were classified as the unimproved group. Patient characteristics, cervical sagittal parameters, neck and arm pain visual analog scale score, and Japanese Orthopaedic Association (JOA) score were assessed. A comparison between the improved and unimproved groups was performed. Regression analyses were performed to identify factors associated with CCLF grade improvement.

RESULTS Overall, 58.0% (69/119) of patients showed improvement in CCLF grade after ACDF. CCLF grade did not improve in the remaining 42.0% (50/119) of patients, and 3.4% (4/119) of patients experienced aggravation of CCLF after ACDF. Preoperative spondylolisthesis (OR 0.252, 95% CI 0.090–0.711; p = 0.009) and greater segmental lordosis 3 months postoperatively (OR 0.835, 95% CI 0.731–0.953; p = 0.008) were the factors that hindered the improvement of CCLF after ACDF. Furthermore, patients with higher pre- or postoperative CCLF grades showed significantly less improvement in JOA score 2 years postoperatively.

CONCLUSIONS Indirect decompression for CCLF with ACDF is not reliable because 42.0% of patients did not demonstrate improvement in CCLF grade after the operation. Preoperative spondylolisthesis and postoperative increased segmental lordosis were risk factors for failure of CCLF improvement. Both pre- and postoperative higher CCLF grades were associated with poor neurological recovery 2 years postoperatively.

 

Posted on

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.

Posted on

Transforaminal lumbar interbody fusion subsidence

J Neurosurg Spine 41:463–472, 2024

The aims of this study were to 1) define the incidence of transforaminal lumbar interbody fusion (TLIF) interbody subsidence; 2) determine the relative importance of preoperative and intraoperative patient- and instrumentation-specific risk factors predictive of postoperative subsidence using CT-based assessment; and 3) determine the impact of TLIF subsidence on postoperative complications and fusion rates.

METHODS All adult patients who underwent one- or two-level TLIF for lumbar degenerative conditions at a multi-institutional academic center between 2017 and 2019 were retrospectively identified. Patients with traumatic injury, infection, malignancy, previous fusion at the index level, combined anterior-posterior procedures, surgery with greater than two TLIF levels, or incomplete follow-up were excluded. Interbody subsidence at the superior and inferior endplates of each TLIF level was directly measured on the endplate-facing surface of both coronal and sagittal CT scans obtained greater than 6 months postoperatively. Patients were grouped based on the maximum subsidence at each operative level classified as mild, moderate, or severe based on previously documented < 2-mm, 2- to 4-mm, and ≥ 4-mm thresholds, respectively. Univariate and regression analyses compared patient demographics, medical comorbidities, preoperative bone quality, surgical factors including interbody cage parameters, and fusion and complication rates across subsidence groups.

RESULTS A total of 67 patients with 85 unique fusion levels met the inclusion and exclusion criteria. Overall, 28% of levels exhibited moderate subsidence and 35% showed severe subsidence after TLIF with no significant difference in the superior and inferior endplate subsidence. Moderate (≥ 2-mm) and severe (≥ 4-mm) subsidence were significantly associated with decreases in cage surface area and Taillard index as well as interbody cages with polyetheretherketone (PEEK) material and sawtooth surface geometry. Severe subsidence was also significantly associated with taller preoperative disc spaces, decreased vertebral Hounsfield units (HU), the absence of bone morphogenetic protein (BMP) use, and smooth cage surfaces. Regression analysis revealed decreases in Taillard index, cage surface area, and HU, and the absence of BMP use predicted subsidence. Severe subsidence was found to be a predictor of pseudarthrosis but was not significantly associated with revision surgery.

CONCLUSIONS Patient-level risk factors for TLIF subsidence included decreased HU and increased preoperative disc height. Intraoperative risk factors for TLIF subsidence were decreased cage surface area, PEEK cage material, bullet cages, posterior cage positioning, smooth cage surfaces, and sawtooth surface designs. Severe subsidence predicted TLIF pseudarthrosis; however, the causality of this relationship remains unclear.

Posted on

Full-endoscopic lumbar discectomy for lumbar disc herniation in young adults: 199 consecutive cases treated by a single surgeon with a mean 3.7-year follow-up

J Neurosurg Spine 41:369–377, 2024

Lumbar disc herniation (LDH) is rare in young adults. The present study aimed to evaluate the clinical outcomes of full-endoscopic lumbar discectomy (FELD) for LDH in young adults and to determine the risk factors that predict unfavorable outcomes of FELD for LDH in young adults.

METHODS A retrospective two-center cohort study was performed between January 2015 and October 2021 at the authors’ institutions. Clinical outcomes were assessed using the visual analog scale (VAS) for low-back pain and leg pain and the Oswestry Disability Index (ODI). The modified Macnab criteria were used to evaluate clinical efficacy at the last follow-up, and the global outcomes were classified into 4 groups, namely excellent, good, fair, and poor. The fair and poor groups were defined as unfavorable outcomes.

RESULTS One hundred ninety-nine patients were analyzed in this study (mean age 18.5 years, mean BMI 25.1 kg/m 2 , male/female sex ratio 2.8). The duration from the onset of symptoms to the operation was in general prolonged with age. The VAS and ODI scores significantly improved after surgery. A total of 17 of 195 single-segment cases had unfavorable outcomes based on the modified Macnab criteria. Lateral disc herniation (OR 3.72, 95% CI 1.14–12.12, p = 0.029) and high preoperative VAS score (OR 1.98, 95% CI 1.13–3.46, p = 0.017) were identified as risk factors for unfavorable outcomes after FELD.

CONCLUSIONS FELD for LDH in young adults is safe and effective. Preoperative VAS score and lateral disc herniation are risk factors of nonfavorable outcomes after surgery and may be a useful index for surgical procedure selection.

Posted on

Radiographic Risk Factors for Adjacent Segment Disease Following Anterior Cervical Discectomy and Fusion (ACDF): A Systematic Review and Meta-Analysis

Global Spine Journal 2024, Vol. 14(7) 2183–2200

Study Design: Systematic review and meta-analysis.

Objectives: To assess the radiographic risk factors for adjacent segment disease (ASD) following anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathologies.

Methods: PubMed, Embase and the Cochrane Library databases were searched up to December 2023. The primary inclusion criteria were degenerative spinal conditions treated with ACDF, comparing radiological parameters in patients with and without postoperative ASD. The radiographic parameters included intervertebral disc height, cervical sagittal alignment, sagittal segmental alignment, range of motion, segmental height, T1 slope, sagittal vertical axis (SVA), thoracic inlet angle (TIA), and plate to disc distance (PPD). Risk of bias was assessed for all studies. The Cochrane Review Manager was utilized to perform the meta-analysis.

Results: From 7044 articles, 13 retrospective studies were included in the final analysis. Three studies had “not serious” bias and the other 10 studies had serious or very serious bias. The total number of patients in the included studies was 1799 patients. Five studies included single-level ACDF, 2 studies included multi-level ACDF, and 6 studies included single or multi-level ACDF. On meta-analysis, the significant risk factors associated with ASD development were reduced postoperative cervical lordosis (mean difference [MD] = 3.35°, P = .002), reduced last-follow-up cervical lordosis (MD = À3.02°, P = .0003), increased preoperative to postoperative cervical sagittal alignment change (MD = À3.68°, P = .03), and the presence of developmental cervical canal stenosis (Odds ratio [OR] = 4.17, P < .001).

Conclusions: Decreased postoperative cervical lordosis, greater change in cervical sagittal alignment and developmental cervical canal stenosis were associated with an increased risk of ASD following ACDF.

Posted on

Risk factors for vascular injuries in anterior lumbar interbody fusion

J Neurosurg Spine 41:17–23, 2024

Vascular injuries in anterior lumbar interbody fusion (ALIF) occur due to the vascular manipulation needed to achieve optimal disc space exposure. In this study, the authors aimed to evaluate intraoperative vascular injuries in patients undergoing single- and multilevel ALIF at a large tertiary academic center.

METHODS Prospectively collected data specifically addressing postoperative complications in patients who underwent ALIF by neurosurgery spine faculty working with a specialized vascular surgeon were retrospectively reviewed. Demographic characteristics and intraoperative data were collected. Patients were split into vascular injury and non–vascular injury groups. Outcome comparisons were conducted using the chi-square exact and Wilcoxon rank-sum tests for categorical and continuous data, respectively. Logistic regression was used to investigate associations with vascular injury, with univariate analysis first conducted to identify candidate associations. Based on these results, variables demonstrating a between-groups test statistic of p < 0.10 were included in the multivariate analysis to determine the independent predictors of vascular injuries.

RESULTS In total, 323 patients who underwent ALIF procedures were identified: 51% were male (n = 166) and 49% were female (n = 157). The mean age was 57.1 years, with 56% (n = 182) having undergone prior lumbar surgery. Vascular injuries were encountered intraoperatively in 7.1% (n = 23) of patients, and the majority (91% [n = 21]) involved the left common iliac vein. Patients with vascular injuries were statistically older (mean 63.6 vs 56.6 years), had greater incidence rates of coronary artery disease, opioid use, multilevel ALIF surgery involving the L2–3 level, and surgery involving multiple disc spaces, had more multilevel anterior instrumentation, and experienced greater blood loss during surgery and longer length of stay (all p < 0.05). Overall, there was 1 death (0.3%) secondary to aortic artery injury. Multivariate analysis identified opioid use, multilevel ALIF involving L2–3, and multiple interbodies as statistically independent predictors of vascular injury (all p < 0.05).

CONCLUSIONS Identifying patient risk factors can reduce the risk of vascular injuries in ALIF. Opioid use, multilevel ALIF involving L2–3, and multiple interbodies were independent predictors of vascular injuries in ALIF.

Posted on

Risk factors of adjacent-segment disease after short-segment fusion in patients with de novo degenerative lumbar scoliosis

J Neurosurg Spine 40:570–579, 2024

Short-segment fusion (SSF) is an effective surgical option for appropriately selected patients with de novo degenerative lumbar scoliosis (DNDLS). Considering that DNDLS is frequently accompanied by multisegment degeneration and potential instability across the entire lumbar segments, it is inevitable that unhealthy segments remain after SSF, thereby increasing the potential risk of adjacent-segment disease (ASD) occurrence. Therefore, the authors aimed to identify the risk factors for ASD in patients with DNDLS who underwent SSF.

METHODS This retrospective study included 80 patients with DNDLS (Cobb angle > 10°) who underwent SSF (1 or 2 levels) between December 2010 and July 2018 with a minimum follow-up duration of 5 years. The participants were divided into two groups: ASD and non-ASD. ASD was defined as clinical ASD rather than radiographic ASD. Various patient and operative variables were compared between the groups. Global and regional radiographic parameters (preoperatively and postoperatively) were also compared between the two groups using plain radiography and MRI. Consequently, univariate and multivariate analyses were conducted to identify the risk factors for ASD occurrence. The receiver operating characteristic (ROC) curve was used to calculate the cutoff values.

RESULTS The mean ± SD age was 67.7 ± 7.2 years at the time of SSF, and there were 62 women (77.5%) enrolled in the study. Thirty patients (37.5%) were in the ASD group and 50 patients (62.5%) were in the non-ASD group. The mean time from the surgery to ASD diagnosis was 34.9 ± 28.2 months in ASD group. Thirteen patients required revision surgery at a mean time of 8.8 ± 7.0 months after ASD occurrence. Multivariate logistic regression analysis demonstrated that preoperative disc wedging angle (OR 1.806, 95% CI 1.255–2.598, p = 0.001), presence of facet tropism (defined as ≥ 10° difference between the facet joint angles of the right and left sides) (OR 5.534, 95% CI 1.528–20.040, p = 0.009), and foraminal stenosis ≥ grade 2 (OR 5.935, 95% CI 1.253–28.117, p = 0.025) were significant risk factors for ASD development. The cutoff value of the preoperative disc wedging angle was calculated to be 2.5° using the ROC curve.

CONCLUSIONS Preoperative disc wedging angle ≥ 2.5°, presence of facet tropism, and foraminal stenosis ≥ grade 2 were identified as significant risk factors for ASD development after SSF in patients with DNDLS.

Posted on

Transforaminal Lumbar Interbody Fusion Versus Posterolateral Fusion Alone in the Treatment of Grade 1 Degenerative Spondylolisthesis

Neurosurgery 93:186–197, 2023

Transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone are two operations performed to treat degenerative lumbar spondylolisthesis. To date, it is unclear which operation leads to better outcomes.

OBJECTIVE: To compare TLIF vs PLF alone regarding long-term reoperation rates, complications, and patient-reported outcome measures (PROMs) in patients with degenerative grade 1 spondylolisthesis.

METHODS: A retrospective cohort study using prospectively collected data between October 2010 and May 2021 was undertaken. Inclusion criteria were patients aged 18 years or older with grade 1 degenerative spondylolisthesis undergoing elective, single-level, open posterior lumbar decompression and instrumented fusion with ≥1-year follow-up. The primary exposure was presence of TLIF vs PLF without interbody fusion. The primary outcome was reoperation. Secondary outcomes included complications, readmission, discharge disposition, return to work, and PROMs at 3 and 12 months postoperatively, including Numeric Rating Scale-Back/Leg and Oswestry Disability Index. Minimum clinically important difference of PROMs was set at 30% improvement from baseline.

RESULTS: Of 546 patients, 373 (68.3%) underwent TLIF and 173 underwent (31.7%) PLF. Median follow-up was 6.1 years (IQR = 3.6-9.0), with 339 (62.1%) >5-year follow-up. Multivariable logistic regression showed that patients undergoing TLIF had a lower odds of reoperation compared with PLF alone (odds ratio = 0.23, 95% CI = 0.54-0.99, P = .048). Among patients with >5-year follow-up, the same trend was seen (odds ratio = 0.15, 95% CI = 0.03-0.95, P = .045). No differences were observed in 90-day complications (P = .487) and readmission rates (P = .230) or minimum clinically important difference PROMs.

CONCLUSION: In a retrospective cohort study from a prospectively maintained registry, patients with grade 1 degenerative spondylolisthesis undergoing TLIF had significantly lower long-term reoperation rates than those undergoing PLF.

Posted on

Rehemorrhage of brainstem cavernous malformations: a benchmark approach to individualized risk and severity assessment

J Neurosurg 139:94–105, 2023

Brainstem cavernous malformations (BSCMs) represent a unique subgroup of cavernous malformations with more hemorrhagic presentation and technical challenges. This study aimed to provide individualized assessment of the rehemorrhage clustering risk of BSCMs after the first symptomatic hemorrhage and to identify patients at higher risk of neurological deterioration after new hemorrhage, which would help in clinical decision-making.

METHODS A total of 123 consecutive BSCM patients with symptomatic hemorrhage were identified between 2015 and 2022, with untreated follow-up > 12 months or subsequent hemorrhage during the untreated follow-up. Nomograms were proposed to individualize the assessment of subsequent hemorrhage risk and neurological status (determined by the modified Rankin Scale [mRS] score) after future hemorrhage. The least absolute shrinkage and selector operation (LASSO) regression was used for feature screening. The calibration curve and concordance index (C-index) were used to assess the internal calibration and discrimination performance of the nomograms. Cross-validation was further performed to validate the accuracy of the nomograms.

RESULTS Prior hemorrhage times (adjusted OR [aOR] 6.78 per ictus increase) and Zabramski type I or V (OR 11.04) were associated with rehemorrhage within 1 year. A lower mRS score after previous hemorrhage (aOR 0.38 for a shift to a higher mRS score), Zabramski type I or V (OR 3.41), medulla or midbrain location (aOR 2.77), and multiple cerebral cavernous malformations (aOR 11.76) were associated with worsened neurological status at subsequent hemorrhage. The nomograms showed good accuracy and discrimination, with a C-index of 0.80 for predicting subsequent hemorrhage within 1 year and 0.71 for predicting neurological status after subsequent hemorrhage, which were maintained in cross-validation.

CONCLUSIONS An individualized approach to risk and severity assessment of BSCM rehemorrhage was feasible with clinical and imaging features.

Posted on

Pediatric Vagus Nerve Stimulation: Case Series Outcomes and Future Directions

Neurosurgery 92:1043–1051, 2023

Vagus nerve stimulation (VNS) is a neuromodulatory procedure most extensively studied as an adjunct to medically refractory epilepsy. Despite widespread adoption and decades of clinical experience, clinical predictors of response to VNS remain unclear. OBJECTIVE: To evaluate a retrospective cohort of pediatric patients undergoing VNS at our institution to better understand who may benefit from VNS and identify factors which may predict response to VNS.

METHODS: We conducted a retrospective cohort study examining pediatric patients undergoing VNS over nearly a 20-year span at a single institution. Presurgical evaluation, including demographics, clinical history, and diagnostic electroencephalogram, and imaging findings were examined. Primary outcomes included VNS response.

RESULTS: Two hundred ninety-seven subjects were studied. The mean age at surgery was 10.1 (SD = 4.9, range = 0.8-25.3) years; length of follow-up was a mean of 4.6 years (SD = 3.5, median = 3.9 years, range 1 day-16.1 years). There was no association between demographic factors, epilepsy etiology, or genetic basis and VNS outcomes. There was an association between reduction in main seizure type with positive MRI finding. Of all MRI findings analyzed, brain atrophy was significantly associated with worse VNS outcomes, whereas dysplastic hippocampus and chronic periventricular leukomalacia findings were found to be associated with improved outcomes. Increased seizure semiology variability and seizure type were also associated with improved seizure outcomes.

CONCLUSION: Predicting response to VNS remains difficult, leading to incompletely realized benefits and suboptimal resource utilization. Specific MRI findings and increased seizure semiology variability and type can help guide clinical decision making and patient counseling.

Posted on

Occurrence, Risk Factors, and Consequences of Postoperative Ischemia After Glioma Resection

Neurosurgery 92:125–136, 2023

Postoperative ischemia can lead to neurological deficits and is a known complication of glioma resection. There is inconsistency in documented incidence of ischemia after glioma resection, and the precise cause of ischemia is often unknown.

OBJECTIVE: To assess the incidence of postoperative ischemia and neurological deficits after glioma resection and to evaluate their association with potential risk factors.

METHODS: One hundred thirty-nine patients with 144 surgeries between January 2012 and September 2014 for World Health Organization (WHO) 2016 grade II-IV diffuse supratentorial gliomas with postoperative MRI within 72 hours were retrospectively included. Patient, tumor, and perioperative data were extracted from the electronic patient records. Occurrence of postoperative confluent ischemia, defined as new confluent areas of diffusion restriction, and new or worsened neurological deficits were analyzed univariably and multivariably using logistic regression models.

RESULTS: Postoperative confluent ischemia was found in 64.6% of the cases. Occurrence of confluent ischemia was associated with an insular location (P = .042) and intraoperative administration of vasopressors (P = .024) in multivariable analysis. Glioma location in the temporal lobe was related to an absence of confluent ischemia (P = .01). Any new or worsened neurological deficits occurred in 30.6% and 20.9% at discharge from the hospital and at first follow-up, respectively. Occurrence of ischemia was significantly associated with the presence of novel neurological deficits at discharge (P = .013) and after 3 months (P = .024).

CONCLUSION: Postoperative ischemia and neurological deficit were significantly correlated. Intraoperative administration of vasopressors, insular glioma involvement, and absence of temporal lobe involvement were significantly associated with postoperative ischemia.

Posted on

Medication intake and hemorrhage risk in patients with familial cerebral cavernous malformations

J Neurosurg 137:1088–1094, 2022

The objective of this study was to analyze the impact of medication intake on hemorrhage risk in patients with familial cerebral cavernous malformation (FCCM).

METHODS The authors’ institutional database was screened for patients with FCCM who had been admitted to their department between 2003 and 2020. Patients with a complete magnetic resonance imaging (MRI) data set, evidence of multiple CCMs, clinical baseline characteristics, and follow-up (FU) examination were included in the study. The authors assessed the influence of medication intake on first or recurrent intracerebral hemorrhage (ICH) using univariate and multivariate logistic regression adjusted for age and sex. The longitudinal cumulative 5-year risk of hemorrhage was calculated by applying Kaplan-Meier and Cox regression analyses adjusted for age and sex.

RESULTS Two hundred five patients with FCCMs were included in the study. Multivariate Cox regression analysis revealed ICH as a predictor for recurrent hemorrhage during the 5-year FU. The authors also noted a tendency toward a decreased association with ICH during FU in patients on statin medication (HR 0.22, 95% CI 0.03–1.68, p = 0.143), although the relationship was not statistically significant. No bleeding events were observed in patients on antithrombotic therapy. Kaplan-Meier analysis and log-rank test showed a tendency toward a low risk of ICH during FU in patients on antithrombotic therapy (p = 0.085), as well as those on statin therapy (p = 0.193). The cumulative 5-year risk of bleeding was 22.82% (95% CI 17.33%–29.38%) for the entire cohort, 31.41% (95% CI 23.26%–40.83%) for patients with a history of ICH, 26.54% (95% CI 11.13%–49.7%) for individuals on beta-blocker medication, 6.25% (95% CI 0.33%–32.29%) for patients on statin medication, and 0% (95% CI 0%–30.13%) for patients on antithrombotic medication.

CONCLUSIONS ICH at diagnosis was identified as a risk factor for recurrent hemorrhage. Although the relationships were not statistically significant, statin and antithrombotic medication tended to be associated with decreased bleeding events.

Posted on

Neurological event prediction for patients with symptomatic cerebral cavernous malformation: the BLED 2 score

J Neurosurg 137:344–351, 2022

Retrospective patient cohort studies have identified risk factors associated with recurrent focal neurological events in patients with symptomatic cerebral cavernous malformations (CCMs). Using a prospectively maintained database of patients with CCMs, this study identified key risk factors for recurrent neurological events in patients with symptomatic CCM. A simple scoring system and risk stratification calculator was then created to predict future neurological events in patients with symptomatic CCMs.

METHODS This was a dual-center, prospectively acquired, retrospectively analyzed cohort study. Adult patients who presented with symptomatic CCMs causing focal neurological deficits or seizures were uniformly treated and clinically followed from the time of diagnosis onward. Baseline variables included age, sex, history of intracerebral hemorrhage, lesion multiplicity, location, eloquence, size, number of past neurological events, and duration since last event. Stepwise multivariable Cox regression was used to derive independent predictors of recurrent neurological events, and predictive accuracy was assessed. A scoring system based on the relative magnitude of each risk factor was devised, and KaplanMeier curve analysis was used to compare event-free survival among patients with different score values. Subsequently, 1-, 2-, and 5-year neurological event rates were calculated for every score value on the basis of the final model.

RESULTS In total, 126 (47%) of 270 patients met the inclusion criteria. During the mean (interquartile range) follow-up of 54.4 (12–66) months, 55 patients (44%) experienced recurrent neurological events. Multivariable analysis yielded 4 risk factors: bleeding at presentation (HR 1.92, p = 0.048), large size ≥ 12 mm (HR 2.06, p = 0.016), eloquent location (HR 3.01, p = 0.013), and duration ≤ 1 year since last event (HR 9.28, p = 0.002). The model achieved an optimism-corrected c-statistic of 0.7209. All factors were assigned 1 point, except duration from last event which was assigned 2 points. The acronym BLED 2 summarizes the scoring system. The 1-, 2-, and 5-year risks of a recurrent neurological event ranged from 0.6%, 1.2%, and 2.3%, respectively, for patients with a BLED 2 score of 0, to 48%, 74%, and 93%, respectively, for patients with a BLED 2 score of 5.

CONCLUSIONS The BLED 2 risk score predicts prospective neurological events in symptomatic CCM patients.

Posted on

Complications of degenerative lumbar spondylolisthesis and stenosis surgery in patients over 80 s

Acta Neurochirurgica (2022) 164:923–931

Degenerative spondylolisthesis (DS) is a debilitating condition that carries a high economic burden. As the global population ages, the number of patients over 80 years old demanding spinal fusion is constantly rising. Therefore, neurosurgeons often face the important decision as to whether to perform surgery or not in this age group, commonly perceived at high risk for complications.

Methods Six hundred seventy-eight elder patients, who underwent posterolateral lumbar fusion for DS (performed in three different centers) from 2012 to 2020, were screened for medical, early and late surgical complications and for the presence of potential preoperative risk factors. Patients were divided in three categories based on their age: (1) 60–69 years, (2) 70–79 years, (3) 80 and over. Multiple logistic regression was used to determine the predictive power of age and of other risk factors (i.e., ASA score; BMI; sex; presence or absence of insulin-dependent and -independent diabetes, use of anticoagulants, use of antiaggregants and osteoporosis) for the development of postoperative complications.

Results In univariate analysis, age was significantly and positively correlated with medical complications. However, when controls for other risk factors were added in the regressions, age never reached significance, with the only noticeable exception of cerebrovascular accidents. ASA score and BMI were the two risk factors that significantly correlated with the higher numbers of complication rates (especially medical).

Conclusion Patients of different age but with comparable preoperative risk factors share similar postoperative morbidity rates. When considering octogenarians for lumbar arthrodesis, the importance of biological age overrides that of chronological.

Proudly powered by WordPress